Play Learn Share My H&S Account Reporting an Incident or Near-Miss. Incident Report Hi, What is your name? * The name of the person completing this report. Did this near-miss put someone's life at serious risk on injury or death? * No Yes When did it happen? * Where did it happen? * Please provide the site address and the location of the incident of the site e.g. At the entrance in front of the office door... Time of the Accident / Incident * 121234567891011 : 00153045 AMPM Date Reported: * Who was involved in the incident? Please add one person at a time. Name: * Date of Birth: Phone Number: * Length of Employment if applicable: plus4 Add person minus4 Remove person Was any property or equipment damaged? * Yes No What was damaged? * What is the nature of the damage? * What was the object or substance that caused the damage? * Are you able to upload or take a photo of it? Drop a file here or click to upload Choose File Maximum file size: 104.86MB You're doing great! Lets talk about what happened, please tell me in a few sentences what happened? * If you are able to or have taken a photo of the incident or near-miss, please upload it here: Drop a file here or click to upload Choose File Maximum file size: 104.86MB Let's investigate this near-miss, what do you think might have caused it? * How bad could it have been? * ModerateMajor / Death Please select How likely is this to happen again? * NeverRarelyOccasionallyOften Please select What action has, or will be taken to prevent this near-miss turning into an accident where people could get hurt? * Who is responsible for making sure this action has been completed? * When will this action be completed by? * Did anyone help you with this investigation? * Yes No What are the names of the people who helped you? IMPORTANT!! Because this near-miss had the potential to cause serious injury, illness, or death you will need to notify WorkSafe about this incident. You must preserve the scene where possible/safe to do so. If you can not safely preserve the scene, please take photos of the scene accordingly. Please contact SafeStaff after completing his report and we will confirm the need to notify and help you through this process. Summary If you are human, leave this field blank. ContinueSubmit Use Shift+Tab to go back Back to home.
