Near Miss Incident Accident Report and Investigation Form
Near Miss Incident Accident Report and Investigation Form
Near Miss Incident Accident Report and Investigation Form
1.
Person(s) Involved:
Name:
Contact No:
Employee:
2.
Department / Section:
Student:
Contractor:
Other (Specify):
3.
am / pm
Severity:
Fatal
4.
Time:
Serious Harm
Minor Harm
Treatment:
Nil
First Aid
H&CC
Doctor
Hospital
By Whom
5.
6.
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
7.
Y/N
If yes, please investigate this hazard and update the Hazard Register in your department or section accordingly
8.
9.
Daily
Weekly
Monthly
Corrective Action: (What will be done to minimise the risk of this happening again)
Action
10.
6 Monthly +
By Whom
Name:
Signed:
Position:
Completed
Managers Comments:
Signed:
Position:
Date:
11.
12.
Y/N
Y/N
Date:
Near Miss / Incident / Accident recorded on Accident Register and all corrective actions completed:
Signed:
Date:
June 2005
June 2005