Incident, Near Miss and Hazard Report Form
v2.0
Purpose. Workers complete this form to report an injury, near miss, hazard, property damage or environmental spill so that it can be recorded in the Incident and Hazard Register and investigated.
1.When to use this form
Use this form for any event that hurt someone, could have hurt someone, damaged property or released a substance to the environment. Report the event to your supervisor first, then complete this form before the end of your shift. Do not wait for all the facts; record what you know and the WHS and Quality Coordinator will follow up.
2.Immediate actions
Make the area safe, give or call for first aid, tag out any plant involved and preserve the scene if someone was seriously injured. A serious injury, a hoist failure or a high-voltage exposure must be reported to the Service Manager and the WHS and Quality Coordinator by phone immediately.
3.Completing the form
Describe what happened in plain language, name the equipment, vehicle and location, and list anyone who saw the event. Rate the potential consequence honestly. Attach photographs where they help.
4.What happens next
The WHS and Quality Coordinator enters the report in the Incident and Hazard Register within one business day, assigns an investigator for anything with a medium or higher consequence and tracks corrective actions to closure. The person who reported the event will be told the outcome.
5.Privacy
Personal information on this form is used only for safety management, workers compensation and regulatory reporting and is stored in the restricted safety folder.