Title Page
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Site conducted
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Date and time of reported incident
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Who reported the incident?
Background Information
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Site address
Person
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Name of person/s involved
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Title/ Position of person/s involved
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Site Manager Name
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Were there any witnesses? If yes, please give full details.
Incident Details
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Date and time of incident
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GPS location of where incident occured
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Details of what happened
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Supporting photos of near miss
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Personal Protective Equipment (PPE) used? If no, why?
Corrective Action
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What should have been done or has been done to prevent this incident from reoccuring? e.g. employee training, change of procedures, purchasing of equipment etc.
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Name of responsible party for corrective actions
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General observations/any further information
Sign Off
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Name of person completing this form
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Signature of person who completed form
