Hazard, Near Miss & Incident Reporting

This form must be completed to report any hazard, near miss or incident within the workplace, including at WIOA conferences and events to ensure an effective response and that control measures are reviewed and revised as necessary.

Note: Death, serious illness or injury and dangerous incidents must be reported immediately to the health and safety regulator.

Hazard, Near Miss & Incident Report Form

Report Form for all Hazards, Near Misses & Incidents for all WIOA events.

Comments

This field is for validation purposes and should be left unchanged.

PART A - To be Completed by the Person Reporting

What are you reporting?(Required)

Date of incident or hazard observed(Required)

Time of incident or hazard observed (24 hr time)(Required)

Reporter's Name(Required)

First Last

Reporter's Position(Required)

Reporter's Company Name(Required)

Reporter's Email(Required)

Enter Email Confirm Email

Mobile Phone(Required)

Business Phone

Event Name

If the incident/hazard occurred at a WIOA event, please provide the name of the event.

Location/area of the incident or hazard(Required)

Work/activity being undertake at time of the incident (identify any plant, substance, equipment involved)(Required)

Description of the incident or hazard: (in your own words, what happened?)(Required)

Please upload photos of the incident/hazard if available

Max. file size: 128 MB.

Witness 1 Name (if any)

First Last

Witness 1 Mobile Phone (if any)

Witness 2 Name (if any)

First Last

Witness 2 Mobile Phone (if any)

Details of Injuries Sustained (if applicable)

Please include the name, injury type and treatment provided to all injured parties.

Please upload photos of the injuries/treatment if appropriate/available.

Max. file size: 128 MB.

Did the incident involve any other person/persons?(Required)

Name of other person involved (if applicable)

First Last

Phone (Mobile preferred)

Name of other person involved (if applicable)

First Last

Phone (Mobile preferred)

Did any property Damage Occur?(Required)

Details of Property Damage

Please provide a thorough description of all property damaged and details of the damage. If available, please upload photos below.

Please upload photos of the property damage if available

Max. file size: 128 MB.

Has the area been secured to prevent unauthorised access and further incidents?(Required)

Are immediate corrective actions required to render the area safe or to eliminate or minimise an immediate risk?(Required)

Actions Taken to Make the Area Safe

Please provide details of what action was taken, the person responsible for the action, and the date and time the action was taken.

Was the hazard/incident verbally reported to a manager or supervisor?(Required)

Manager/Supervisor's Name

First Last

Manager/Supervisor's Company

Manager/Supervisor's Mobile Phone

If the incident/hazard was verbally reported by someone other than you, please provide their name and mobile phone number here.

If the incident/hazard was not reported to a manager/supervisor, please explain why.

Hazard, Near Miss & Incident Reporting

Hazard, Near Miss & Incident Report Form

PART A - To be Completed by the Person Reporting

Follow us