Incident, Near Miss and Hazard Report Form
v3.2
Purpose. This form records every injury, near miss, hazard, equipment damage and environmental incident so that it can be investigated and controlled.
1.When to use this form
Any worker must complete this form for any injury, illness, near miss, hazard, property damage or environmental incident, before the end of the shift. Where the person involved cannot complete it, the supervisor will complete it with them. The form is entered in the Incident and Hazard Register by the supervisor.
2.Describing what happened
Describe the task being done, the equipment involved, the sequence of events and what stopped it from being worse. Record the facts you saw, not the cause you assume. Attach photographs where they help.
3.Injuries and treatment
Record the part of the body injured, the treatment given, and whether the person was sent to the medical centre or hospital. Record the name of the first aider. Injuries that require medical treatment or lost time must be reported to the HSE Manager on the day.
4.Immediate controls
State what has been done to make the area safe now, such as isolating equipment, barricading, or stopping the task. The supervisor must confirm the immediate controls before the crew continues.
- Isolate or barricade
- Notify the area operator
- Stop the task if the hazard is not controlled
5.Classification and follow-up
The supervisor will classify the potential severity using the site matrix and will decide whether an investigation is required. Serious potential incidents must be investigated to root cause by the HSE team. The form must be signed by the reporter and the supervisor.