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    Near Miss Incident Accident Report and Investigation Form

    Uploaded by

    hutomo_90
    This form is used to report and investigate near misses, incidents, and accidents. It collects information about the persons and location involved, a description of what happened, and the perceived causes. Corrective actions must be identified to minimize future risk, along with manager and health & safety coordinator comments. For serious harm, contact numbers are provided to immediately report the event.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Near Miss Incident Accident Report and Investigation Form

    Uploaded by

    hutomo_90
    170 views3 pages
    This form is used to report and investigate near misses, incidents, and accidents. It collects information about the persons and location involved, a description of what happened, and the perceived causes. Corrective actions must be identified to minimize future risk, along with manager and health & safety coordinator comments. For serious harm, contact numbers are provided to immediately report the event.

    Original Description:

    Near Miss Incident Accident Report and Investigation Form

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    This form is used to report and investigate near misses, incidents, and accidents. It collects information about the persons and location involved, a description of what happened, and the perceived causes. Corrective actions must be identified to minimize future risk, along with manager and health & safety coordinator comments. For serious harm, contact numbers are provided to immediately report the event.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    170 views3 pages

    Near Miss Incident Accident Report and Investigation Form

    Uploaded by

    hutomo_90
    This form is used to report and investigate near misses, incidents, and accidents. It collects information about the persons and location involved, a description of what happened, and the perceived causes. Corrective actions must be identified to minimize future risk, along with manager and health & safety coordinator comments. For serious harm, contact numbers are provided to immediately report the event.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 3
    At a glance
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    The document outlines a form and process for reporting and investigating near misses, incidents and accidents at work.

    The form collects details about the people involved, location, date/time, severity of injury, treatment received, description of the event, causes, hazards identified and chance of recurrence.

    The completed form needs to be sent to the Health and Safety Coordinator, with corrective actions taken to prevent recurrence and hazards updated in the hazard register if needed.

    Near Miss / Incident / Accident

    Report & Investigation Form


    This form must be completed with corrective actions and Managers comments before returning it to the
    Health and Safety Co-ordinator, C Block, within 48 hours.
    In the case of Serious Harm or possible Serious Harm, please contact the Health & Safety Co-ordinator on extn 9949,
    the Occupational Health Nurse on extn 9983 or Campus Security on extn 8700 immediately.

    1.

    Person(s) Involved:
    Name:
    Contact No:
    Employee:

    2.

    Department / Section:
    Student:

    Contractor:

    Other (Specify):

    Details of near miss / incident / accident:


    Location:
    Date:

    3.

    am / pm

    Severity:
    Fatal

    4.

    Time:

    Serious Harm

    Minor Harm

    No Harm / Near Miss

    Treatment:
    Nil

    First Aid

    H&CC

    Doctor

    Hospital

    What treatment was given ?

    By Whom
    5.

    Description of what happened:

    6.

    Describe the cause of the near miss / incident / accident:

    Contributory Factors (refer to these when identifying the cause of the near miss / incident / accident)
    Immediate Causes
    - Guarding
    - Defective tools or equipment
    - Hazardous arrangements
    - Unsafe conditions
    - Unsafe design
    - Housekeeping
    - Environmental conditions

    Substandard Acts
    - Operating without authority
    - Disabling safety devices
    - Using unsafe equipment
    - Non use of Personal Protective Equipment
    - Non use of lock out / isolation systems
    - Unsafe positioning
    - Distraction / fooling about

    Please complete the other side of this form


    June 2005

    7.

    Has a significant hazard been identified ?

    Y/N

    If yes, please investigate this hazard and update the Hazard Register in your department or section accordingly
    8.

    Chance of the near miss, incident or accident recurring:


    One off

    9.

    Daily

    Weekly

    Monthly

    Corrective Action: (What will be done to minimise the risk of this happening again)
    Action

    10.

    6 Monthly +

    By Whom

    Person in control of the workplace:

    Name:

    Signed:

    Position:

    Completed

    Managers Comments:

    Signed:

    Position:

    Date:
    11.

    12.

    Health and Safety Co-ordinators comments:

    Is post critical event testing required

    Y/N

    If yes, advise Occupational Health Nurse

    Y/N

    Date:

    Near Miss / Incident / Accident recorded on Accident Register and all corrective actions completed:
    Signed:

    Date:
    June 2005

    Retain a copy on the department / section file


    Send completed original to Health and Safety Co-ordinator

    June 2005

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