Incident / Near-Miss Report Form

Hazard, Near Miss, Incident & Accident Report Form

White Building Company requires all hazards, near miss’, incidents and or accidents to be reported as soon as practical. Please ensure that the site supervisor is notified of the undesired event as soon as possible.

CLASS OF INCIDENT(Required)

Injury

Property/Plant Damage

Near Miss

Environmental

Other

REPORTED(Required)

Yes

Details:(Required)

FURTHER ACTION REQUIRED

Report to Authorities

Other

DETAILS OF INCIDENT

Date of Incident(Required)

Time of Incident(Required)

Witness Name (If none list NIL)(Required)

Witness Contact

Nature of Incident(Required)

Location of Incident(Required)

Description of Incident(Required)

Details of damage to equipment/property?

Photos (If able)

Max. file size: 200 MB.

INJURED PERSON/S (IF APPLICABLE)

Name(Required)

Address(Required)

Date of Birth

Occupation(Required)

Employer(Required)

RECOMMENDED PREVENTIVE ACTION

Details

COMPLETED BY

Name(Required)

Position(Required)

Phone(Required)

Signature(Required)

Date(Required)

Incident / Near-Miss Report Form

Hazard, Near Miss, Incident & Accident Report Form

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Incident / Near-Miss Report Form

Hazard, Near Miss, Incident & Accident Report Form

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