Incident, Accident and Hazard Report Form

Near miss: An unplanned event or series of events that occurred at the workplace which, although not
resulting in any injury, illness or equipment/property damage, had the potential to do so.
Accident: An event arising out of work resulting in personal injury or property damage.
Hazard: Any substance, physical effect, or condition with potential to harm people, property, or the
environment.

Name of Project:
Location on site:
Date:
Time:

CHECK ALL APPROPRIATE CONDITIONS

 Incident  Near miss

 `Accident  Hazard
DESCRIPTION

Name: Date:

Signature:

*Fill this form and send to OHS Representative

V1.0 F-OHS-14