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Incident/Accident Report Form
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Incident/Accident Report Form
Incident Report
Department (if applicable)
Supervisor/Manager in Charge
Date
Time of the incident/near miss
Location
Name and role of person
completing this form
Signature of person
completing this form
What was the incident/near miss?
Injury Near miss
Where there any injuries?
Yes No
Details of person who was injured and injury:
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Was there any damage to property or plant?
Yes No
Take photo of surrounding environment including any annotations and attach it to
form if possible
What caused the incident? Who was involved?
What immediate actions were taken?
Possible solutions to prevent future repeats of the incident.
Management comments
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Incident/Accident Report Form
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To be completed by management -Action taken
Responsibility
Completion date
1
2
3
4
Feedback has been provided to the person who reported the incident/accident.
Yes No
Signed off by management when corrective actions have been adopted and monitored.
Management signature_______________________ Date of sign off_________________

Unformatted Attachment Preview

Incident/Accident Report Form Incident/Accident Report Form Incident Report Department (if applicable) Supervisor/Manager in Charge Date Time of the incident/near miss Location Name and role of person completing this form Signature of person completing this form What was the incident/near miss? Injury Near miss Where there any injuries? Yes No Details of person who was injured and injury: Incident/Accident Report Form Page 1 of 3 Incident/Accident Report Form Was there any damage to property or plant? Yes No Take photo of surrounding environment including any annotations and attach it to form if possible What caused the incident? Who was involved? What immediate actions were taken? Possible solutions to prevent future repeats of the incident. Management comments Incident/Accident Report Form Page 2 of 3 Incident/Accident Report Form To be completed by management -Action taken Action Responsibility Completion date 1 2 3 4 Feedback has been provided to the person who reported the incident/accident. Yes No Signed off by management when corrective actions have been adopted and monitored. Management signature_______________________ Incident/Accident Report Form Date of sign off_________________ Page 3 of 3 Name: Description: ...
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