Near Miss and Incident Report Form
This form must be completed the same day as the incident occurs.All personal injury must be flagged to management immediately.
Date of Incident
*
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Month
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Day
Year
Date Picker Icon
incident Time
*
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5
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:
Hour
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10
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30
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50
Minutes
AM
PM
AM/PM Option
Employee Name
*
First Name
Last Name
Witness Name
First Name
Last Name
Location of Incident
*
Type of Incident
Registration Numbers of any Vehicles, Loaders or Trailers damaged
Description of Incident, What Happened?
Were there any injuries? If so, was medical treatment sought?
What caused the incident?
Was there any damage to any property, plant or equipment?
What actions can you take and/or can the company implement to eliminate further repeats of this incident?
Form Completed by;
Please include a photo of any damages or your surroundings that contributed to the incident or near miss
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