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INCIDENT/NEAR MISS REPORT FORM

Details Incident No. Date: Location: Time:

Name of person reporting incident: Supervisor:

Nature of Report (Circle applicable) Near Miss Employee/Visitor Injured Equipment Defect/Damage Environmental Damage

Details of Incident/Near miss

What happened?

Where did it happen?

Why did it happen?

Were there any witnesses?

Verbally Reported To:

Date:

Time:

**Disclaimer: Online Compliance Systems (OCS) expressly disclaim all and any liability to any person in respect of anything, and of consequence of anything done or omitted to be done by any or such person in reliance, whether wholly or partially on this generic OHS Document. It is highly recommended that persons who are responsible for preparing and reviewing OH&S Documents undertake training and consult with all employees and seek professional advice prior to implementing this document in their organisation.**

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INCIDENT/NEAR MISS REPORT FORM

Details of person injured Name

Address

Details of injury

Doctor (Name) Treatment of First Aid YES/NO

Hospital (location)

Transportation:

None

Car Driven by:

Taxi

Ambulance

This form was completed by: ____________________________________________________________________________

Signed: ______________________________________

Date: ___________________________________

**Disclaimer: Online Compliance Systems (OCS) expressly disclaim all and any liability to any person in respect of anything, and of consequence of anything done or omitted to be done by any or such person in reliance, whether wholly or partially on this generic OHS Document. It is highly recommended that persons who are responsible for preparing and reviewing OH&S Documents undertake training and consult with all employees and seek professional advice prior to implementing this document in their organisation.**