SAFETY

MOMENT
Microsoft Office
Word Document
 Incident/Accident/ Near miss Reporting Form

Use this form to report any workplace accident, injury, incident, close call or illness.

Return completed form to the Operation Supervisor or Safety team.

This is documenting an:

Kindly highlight which of the following

Injury / First Aid / Incident / Near miss / Observation

Details of person injured or involved (to be filled by person injured / involved if possible)

Person Completing Report:………………………….. Date……………………………….

Person(s) involved: ……………………………….

Equipment / Machinery involved:…………………………………………

Event Details

Date of Event:_______________________ Location of Event_____________________

Time of Event:_________________________ Witness:__________________________

Description of Events (Describe task being performed and sequence of events):

Was event / injury caused by an unsafe act (activity or movement) or an unsafe condition
(machinery or weather)? Please explain: