Hazard & Near Miss Report Form
What are you reporting?
*
Please Select
Hazard
Near-Miss
Something else
Hazard - Something that has potential to harm someone. Near Miss - A close call that could have caused harm.
Back
Next
Save
Details of person involved
Name
*
First Name
Last Name
Mobile Number
*
Format: 0000 000 000.
Job Role
*
Back
Next
Save
Details of Hazard or Near Miss Event
Date event observed
*
-
Day
-
Month
Year
Date
Site of event
*
Please Select
Hemmant, QLD
Condell Park, NSW
Brunswick, VIC
Hallam, VIC
Bassendean, WA
Offsite
Were any of the following involved in this event?
*
Please Select
Truck
Forklift
Other
No
Have you reported this to a team leader or manager?
*
Please Select
Yes
No
I don't feel comfortable doing that
NA
Please provide details of the event that has occurred
*
Is there anything else the Safety Team should be aware of regarding this incident?
*
Did you do anything to stop or prevent the event from happening again?
*
Were there any witnesses to the event?
*
No
Yes
Please provide the witness/es name/s
*
Back
Next
Save
Click SUBMIT below to complete and send your Report Incident Form to the Safety Team
Save
Submit
Should be Empty: