Report incident/near misses form
What is your name, job title & company? *
What is your email address? *
What is your usual place of work? *
Type of incident *
- Select - Injury sustained Illness (work related) Environmental Near miss Dangerous occurrence Vehicle incident Other
Where did the incident happen? *
What category best describes the incident? *
- Select - Vehicle collision Manual handling Slip/trip Struck by/struck against Assault physical Assault verbal Electrical Entrapment Environment Use of Equipment/Machinery Exposure to Elements Exposure/Contact with Substance Fall from Height Fire Flood Foreign Body Glass, Sharp Edge Illegal Activity Involving Animals Maintenance Issue Threat/Fear for Personal Safety Unsafe Condition Unsafe Equipment Unsafe Procedure Unsafe/Inappropriate Behaviour Unsafe Environment Other (Specify)
Please provide names and contact details of any witnesses *
Was there an injury as a result of the incident? *
- Select - Yes No
What type of Injury was sustained? *
- Select - N/A Allergic reaction Loss of limb Bite Bruise Bump Burn Scald Coma Concussion Crush Cut Death Disease Foreign Body Fracture Graze Multiple Injuries (Specify) Seizure Sickness Sprain Strain Other (Specify)
Give details including which part of body was affected and/or where damage was sustained *
Please enter type of treatment provided *
Did the injury result in time of work? *
Did the incident involve a vehicle? *
- Select - Yes No
Registration and model of vehicle driven *
Owned, company car, other (please specify) *
Details of damage to vehicle *
Details of damage to 3rd party and/or injury to other individuals *
Submit
