Incident and Near Miss Form

CQ Party Hire and Stage & Audio Event Solutions

Describe the specific location of the incident as well as the address eg inside CQPH warehouse, next to the vinyl washing machine.
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?
e.g. activity, movement, machinery, weather, other
Click or drag a file to this area to upload.
e.g. fracture, laceration, amputation, strain, electrical shock, burn
e.g. wrist, anke, lower back, internal organs
Name of hospital, doctors clinic, attending physcian etc.
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