The document is an incident report form used to report near misses, incidents, or accidents at a company. It collects key details about the nature, location, and cause of the event as well as information about any injuries or corrective actions. The form includes sections to describe the incident, location, injuries sustained, probable root cause, actions taken, and a review by management.
The document is an incident report form used to report near misses, incidents, or accidents at a company. It collects key details about the nature, location, and cause of the event as well as information about any injuries or corrective actions. The form includes sections to describe the incident, location, injuries sustained, probable root cause, actions taken, and a review by management.
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online from Scribd
The document is an incident report form used to report near misses, incidents, or accidents at a company. It collects key details about the nature, location, and cause of the event as well as information about any injuries or corrective actions. The form includes sections to describe the incident, location, injuries sustained, probable root cause, actions taken, and a review by management.
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online from Scribd
NATURE OF THE NEAR MISS INCIDENT ACCIDENT INCIDENT BRIEF DISCRIPTION DATE & PERMANENT SEX: TIME OF NAME OF THE PERSON DEPT. EMPLOYEE/ M( ) F( ) OCCURE CONTRACTOR NCE
ACTION DISPOSITION PROPOSED
CORRECTIVE ACTION TAKEN ACTION PREVENTIVE ACTION INCIDENT ACCIDENT DATE OCCURANCE OF MANHOURS DETAILS OF TREATMENT RESUM LOST LOCATION WITNESSED BY ING BACK FIRST AID SENT TO HOME / HOSPITAL IMPACT OR HAZARD PART OF THE BODY TYPE (TICK THE PROBABLE ROOT CAUSE INJURED APPLICABLE) RESOURCE USE OF HANDS INSTEAD HEAD DEPLETION OF WORKAIDS LAND UNSAFE METHOD OF CONTAMINATI EYE MATERIAL HANDLING ON INEFFECTIVE SAFETY AIR POLLUTION FACE DEVICE WATER UNSAFE STORAGE / NECK POLLUTION PILING HEARING SHOULDER BAD HOUSE KEEPING IMPAIRMENT FAILURE TO USE PPE’S EYE INJURY ARM (GLOVES/GOGGLES/SHOE S/BELT/ HELMET) BRUISES / USE OF UNSAFE / PALM ABRASION DEFECTIVE TOOLS ELECTRIC USE OF UNSAFE / FINGER SHOCK / BURN DEFECTIVE MACHINES USE OF UNSAFE / CUT CHEST DEFECTIVE LADDER FRACTURE / USE OF UNSAFE / BACK PUNCTURE DEFECTIVE PLATFORM MAKING SAFETY DEVICE HEAD INJURY ABDOMEN INOPERATIVE HEALTH THIGH / LEG FAILURE OF PPE’S USED COMPLAINTS / ANKLE OTHERS FOOT / TOE SLIP / TRIP AVOIDABLE. INCIDENT / UN AVOIDABLE ACCIDENT INCIDENT / ACCIDENT INCIDENT / ACCIDENT COMMENTS REVIEWED BY: