Hazard/Near Miss/Incident Report

Hazard Report

Hazard/Near Miss/Incident/Regulatory Visit-Audit
Site & Reporting Details
Site*
Date*

DayMonthYear
Date
Time*

:HourMinutesAM/PM Option
Person Submitting Report*
Full Name
Company (if not RLX)
Email*
example@example.com
Status*
Who was this reported to*
If not verbally reported, type N/A
Type of Report
What type of Report is this?

HazardRegulatory Visit/AuditNear MissProperty DamageIncident

Hazard Report
What type of Hazard is it?*
Describe the Hazard*
What immediate actions have been taken to make safe?*
If 'nothing then write 'Nil.

Incident Report
What type of Incident occurred?

FAIMTILTIProperty DamageEnvironmentalAnimal Related

FAI/MTI/LTI
Who did it happen to?*
e.g. Name, DOB, address, contact number
Role/Company
Person Category*
Description*
e.g. Injury description, treatment (icepack on-site/stitches) & where (site/hospital)
What happened?
What factors were involved?*
Describe incident & activity being undertaken
What has been done?
e.g. Actions taken to make safe
What PPE was worn?*
Type of footwear?*
Injury details - side of body*
Injury details - body part injured*

Property Damage
Name of person involved?*
Role/Compnay
What factors were involved?*
Describe the incident & activity being undertaken*
Describe damage that has occurred

Near Miss
Who was involved?*
Role/Company*
Person Category*
What happened?*
Please include as much detail as possible
What type of Near Miss occurred?*
What factors were involved?*
Why did the event occur?*
Describe the activity being undertaken
How did the event occur?*
e.g. include other parties involved, weather or other conditions

Regulatory Visit/Audit
What Type of Audit?*
Report initial Findings/comments*
Any Directions issued for action?*
If 'nothing then write 'Nil.

Photo & File Uploads
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Other Upload (Optional Images or files limited to 5)

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