Near Miss / Incident / AccidentReport & Investigation Form

In the case of Serious Harm or possible Serious Harm, please contact the Health & Safety department on ext. The Occupational HR on ext. 810. Or 24 hours Emergency on ext. 829 immediately (Security Dept.).

Details of near miss / incident / accident: Location: Quality Assurance Time: 3:12 AM Date: 1/26/2016 Person(s) Involved: Name: ******** Department: Quality Assurance Employee: ☒ Contractor: ☒ Other (Specify): ☒

Type of Injury Part of Body Cause of Injury No Physical Injury Head Contact With Severity: Fatal ☒ Serious Harm ☒ Minor Harm ☒ No Harm / Near Miss ☒ Treatment: Nil ☒ First Aid ☒ H&CC ☒ Doctor ☒ Hospital ☒ What treatment was given? ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ! By Whom: ……………………………! Description of what happened:……………………………………………………………………………………………………………………………………………………………………! Immediate Causes: Unsafe design Substandard Acts: Unsafe positioning

Chance of the near miss, incident or accident recurring: One off ☒ Daily ☒ Weekly ☒ Monthly ☒ 6 Monthly + Corrective Action: (What will be done to minimise the risk of this happening again)

Action: By Whom Completed Click here to enter text. Click here to enter text. Click here to enter text. Person in control of the workplace:

Name: Sign. Position: Dept. HOD Manager’s Comments: …………………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………!

Name: Sign. Position: Dept.Health and Safety Co-coordinator’s comments: …………………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………!

Name: Sign. Position: Dept.Remarks: Description: Near-Miss Report Form A near miss is a potential hazard or incident that has not resulted in any personal injury or property damage. Unsafe conditions, unsafe work habits, improper use of equipment, use of malfunctioning equipment, or unexpected reactions are examples of near-misses. It is everyone's responsibility to report and correct these potential hazards immediately. Please complete this form as a means to report these near miss situations

and help prevent future incidents at company.