Incident and Near Miss Form

CQ Party Hire and Stage & Audio Event Solutions

Reporting employee's name *

First

Last

Reporting employee's email *

Person(s) involved *

Witnesses *

Team Leader or Management on site (if applicable) *

Vehicle(s) involved (if applicable) *

Date / Time of incident *

Date

Time

Location of Event *

Describe the specific location of the incident as well as the address eg inside CQPH warehouse, next to the vinyl washing machine.

Please describe the incident *

Please provide as much detail as possible, for instance: the events that led to the incident; the work being undertaken when the incident happened; the overall action, exposure or event that best describes the circumstances that resulted in the injury, illness, fatality or dangerous incident; the object, substance or circumstance which was directly involved in inflicting the injury, illness, death or dangerous incident; the name and type of any machinery, equipment or substance involved. Was anyone else involved? Was electricity or electrical equipment involved?

Immediate actions taken following the incident: *

e.g. first aid, work stopped, supervisor notified, equipment tagged out, vehicle secured

Was event / injury caused by an unsafe act or condition? Please explain *

What were the contributing factors e.g. activity, movement, machinery, weather or other?

Please upload any photos you wish to share of the injury or damage to property/vehicle

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Description of injury/illness

e.g. fracture, laceration, amputation, strain, electrical shock, burn, heat exhaustion

Body location:

e.g. wrist, anke, lower back, internal organs

Did the person receive treatment following the injury/illness?

Describe the treatment:

Where was the injured person taken for treatment (if applicable):

Name of hospital, doctors clinic, attending physcian etc.

Incident and Near Miss Form

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