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Accident / Incident / Near Miss Record
Person who had the Accident / Incident / Near Miss
Date and Time of Accident / Incident / Near Miss Reporting
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What Type of Occurrence Are You Reporting?
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Accident
Incident
Near Miss
Did the Accident / Incident / Near Miss Occur on a Water Site?
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Name
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Occupation
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Person Filling in this Report
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Name
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Occupation
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Contact Number
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Details of Accident / Incident
Date and Time of Accident / Incident / Near Miss
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Year
Date
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Location of Accident / Incident / Near Miss
How did the Accident / Incident / Near Miss Happen?
If Any Injuries Were Suffered Please Provide Details, Including Location and Severity of Injury
Was First Aid Administered?
Yes
No
What First Aid Was Administered and by Whom?
Name and Contact Details of Any Witnesses
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Details of Near Miss
Date and Time of Near Miss
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Month
Year
Date
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Location of Near Miss
Describe the Near Miss or Unsafe Act Observed
What Remedial Action has Been Taken?
Was first aid administered?
Yes
No
What was the Category of Near Miss?
Housekeeping Standards Inadequate
Housekeeping Standards Not Known or Understood
Housekeeping Standards Not Being Followed
Behaviour - Horseplay
Behaviour - Inattention to Surroundings
Procedural - Procedures Inadequate
Procedural - Procedures Not Known or Understood
Procedural - Procedures Not Being Followed
Training - Not Trained for the Activity
Training - Other Training Not Completed
Contact with / exposure to harmful or biological substance
Contact with electricity or electrical discharge
Contact with hot surface / substance
Contact with moving machinery, object or substance
Contact with sharp object
COVID-19
Drowning or asphyxiation
Employee personal safety (violence / physical or verbal assault
Fall from height
Fire or explosion
Health condition
Injured by animal / insect
Lifting and handling injury
Lifting equipment failure
Lone worker false alarm
Manual handing
Process safety – Activation of safety instrumented system
Process safety – Loss of primary containment
Process safety – Safety critical equipment failed / defeated
Slip, trip, fall polymer spillage
Slip, trip, fall on same level
Struck by moving vehicle
Struck by moving, flying or falling object
Struck, caught against, trapped
Trapped by something overturning / collapsing
Uncontrolled release of hazardous substance
Vehicle collision / road traffic collision
Working time regulations
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Signature
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