Incident / Near Miss Report
Please fill out one form per unit.
Date Submitted
-
Month
-
Day
Year
Date Picker Icon
Event
Please Select
Incident
Near Miss
An incident is an event that did cause injury to a person or damage to equipment, building, or materials. A near miss is an event that could have caused injury to a person or damage to equipment, building or materials.
Form Initiator
Please Select
Amir Dad Hassin
Andy McCann
Christian Artates
Darrin Holoboff
Emmanuel Perron
Howie Ta
Lonny Cluness
Melvin Suyjuarez
Michael Buchan
Mickael Picquet
Rolando Odina
Scott Merriman
Stephane Perron
Thomas Zlotnick
Will Welcher
Yvens Dolcine
Tyler Ashby
David Keogh
David Lacombe
John Whalen
Joseph Knob
Paul Moore
Michael O'Day
Michael Buchan
Will Welcher
Jennifer Patterson
Ciara Redmond
Jennifer Walter
Debbie Buchan
Employee
Please Select
Amir Dad Hassin
Andy McCann
Christian Artates
Darrin Holoboff
Emmanuel Perron
Howie Ta
Lonny Cluness
Melvin Suyjuarez
Michael Buchan
Mickael Picquet
Rolando Odina
Scott Merriman
Stephane Perron
Thomas Zlotnick
Will Welcher
Yvens Dolcine
Tyler Ashby
David Keogh
Paul Moore
Manager
Please Select
Michael Buchan
Will Welcher
David Lacombe
Michael O'Day
Jennifer Patterson
Ciara Redmond
Jennifer Walter
Debbie Buchan
Witness(es)
Date of Event
-
Month
-
Day
Year
Date
Time of Event
Hour Minutes
AM
PM
AM/PM Option
Date Reported
-
Month
-
Day
Year
Date
Location where event occurred
Start of shift on day of event
Hour Minutes
AM
PM
AM/PM Option
End of shift on day of event
Hour Minutes
AM
PM
AM/PM Option
Full description of event
*
List all equipment, machinery, materials or chemicals employee was using when event occurred
*
Identify factors that you believe contributed to or caused the event
*
Nature of injury (strain, cut, bruise, etc.)
*
Body parts affected
*
Medical treatment required:
None
First Aid
Emergency Transport
Doctor or Hospital
Name of Hospital or Attending Physician
Was the employee hospitalized overnight as a patient?
Yes
No
Did employee leave work due to injury?
Yes
No
If Yes, at what time?
Hour Minutes
AM
PM
AM/PM Option
Date of return to regular duty
-
Month
-
Day
Year
Date
Add photos to support each of the above
*
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of
Complete this section if an injury occurred or there was damage to equipment
Were proper procedures being followed when incident occurred?
Yes
No
If No, explain:
Was employee wearing proper personal protective equipment?
Yes
No
If No, explain:
Are changes in equipment necessary to prevent a recurrence?
Yes
No
If Yes, explain:
Employee Signature
Clear
Manager Signature
Clear
Submitted by
Please Select
ahassin@quenchwater.com
amccann@quenchwater.com
cartates@quenchwater.com
dholoboff@quenchwater.com
eperron@quenchwater.com
hta@quenchwater.com
lcluness@quenchwater.com
msuyjuarez@quenchwater.com
mbuchan@quenchwater.com
mpicquet@quenchwater.com
rodina@quenchwater.com
smerriman@quenchwater.com
sperron@quenchwater.com
tzlotnick@quenchwater.com
wwelcher@quenchwater.com
ydolcine@quenchwater.com
tashby@quenchwater.com
dkeogh@quenchwater.com
zsalakian@quenchwater.com
tgrant@quenchwater.com
jpatterson@quenchwater.com
kswift@quenchwater.com
nboswell@quenchwater.com
credmond@quenchwater.com
cma@quenchwater.com
elai@quenchwater.com
jwalter@quenchwater.com
sidrissi@quenchwater.com
znguyen@quenchwater.com
dbuchan@quenchwater.com
fbrunning@quenchwater.com
gkarpfen@quenchwater.com
lharroch@quenchwater.com
dlacombe@quenchwater.com
pmoore@quenchwater.com
Submit
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