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Near-miss incident report form - osha

Please use this form to report near-misses and assist us in preventing future incidents and making the Company a safer workplace. Department: Building/Work Area .  You may use this form to submit a written report of an issue that you have with Company. Company will investigate all safety-related incidents reported to us. You will know when we receive a report from you. Company can only accept written reports of Safety-Related incidents that result in personal injury or property damage. No personal information will ever be collected by Company. For a complete list of the types of Safety-Related incidents, please refer to the below referenced Fact Sheet. Customer Incident Reports Customer Safety Reports Customer Safety Report Number: Customer Safety Report Description: Customer Safety report must include all details of all incidents reported that were not directly related to Company business. Customer Safety Report Number:  Customer Safety Report Description: Customer Safety report must include all details of all incidents reported that were.

Accident incident / near miss report - shrm

You can use your personal insurance card or any other form of proof of coverage. A form other than this one must be sent to the address below to receive reimbursement.

Near-miss report form - environmental health and safety

The near-miss report form is very similar to the Personal Safety and Security questionnaire used as part of an on-campus investigation and includes questions for the investigator to identify specific locations where the individual would feel extremely insecure within a set time period. If a near-miss is determined by the investigator, information is collected from the following locations to determine which areas/places are within safe distance of the identified individual: Place of Work (if not already on the on-campus business/accommodation list; see map below for further explanation) School/College/Campus Places Attended As a Child Neighborhood Community (, neighborhood association) Pace (where the individual is going/has been going) School or College Bus Private Residence The near-miss questionnaire is divided into four areas — Social, Physical and Environmental Factors, Financial Factors and Personal Safety and Security. Each of the four areas can be further subdivided and additional questions requested in some instances to increase the likelihood of a near-miss occurring. The.

Near-miss and accident investigation report

It is designed for reporting incidents of all types which may be related to anti-social behavior. Note: The form requires you to state the name of the Police Officer or other person with responsibility for you, the date, time and location of the incident. You need not include the victim's name.  You are not required to provide any additional information, such as the cause or other details of the incident, or any other details.  It is the responsibility of the individual to provide the evidence needed by police. Further information may be available from police. All police inquiries are anonymous. You're not required to give the name of the police officer or other person who took your complaint to them. If you would like to speak directly to an officer, please call us at the following number: 101 Call us to book a taxi  or walk in any of our branches. You.

Near miss reporting form | free pdf download | safetyculture

For incidents reported by other motorists, these forms are used in much the same way. . . .  . . . . . . .  . . .  In the case of a motorist in an inebriated condition, it is recommended that any motorist who is involved in an accident report the facts of the incident to the police. (emphasis added) If such a near-miss were proven when the investigation was completed, one could reasonably claim that the driver acted unreasonably or negligently. As the report was made “within 90 days” of the near miss, the police would likely have been unable to complete their investigation in time, and the driver could have filed a negligence suit against the other driver.  However, if the information was provided to the police within six months of the accident, or within the statutory period of two years from the accident (both stated timeframes on.