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Near Miss or Incident Investigation

This document outlines a near miss/incident report form for reporting unplanned events that result in injury, illness, or a near miss. The form includes sections to document the location and time of the incident, a description of what happened, information about any injured parties, recommendations to prevent similar incidents, an investigation of the root causes and severity, and an investigation report. It notes that the site manager must inform the HSE department within 24 hours and secure any evidence, and that the HSE manager will select an investigation team to gather data and evaluate the incident.

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Fahad Ahmed
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269 views4 pages

Near Miss or Incident Investigation

This document outlines a near miss/incident report form for reporting unplanned events that result in injury, illness, or a near miss. The form includes sections to document the location and time of the incident, a description of what happened, information about any injured parties, recommendations to prevent similar incidents, an investigation of the root causes and severity, and an investigation report. It notes that the site manager must inform the HSE department within 24 hours and secure any evidence, and that the HSE manager will select an investigation team to gather data and evaluate the incident.

Uploaded by

Fahad Ahmed
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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NEAR MISS / INCIDENT REPORT

REF # :
SITE :
SITE MANAGER :
PERSON INVOLVED :

NOTE
This form should be used to report an unplanned event which resulted in either a near miss or an injury or ill health. The
completed form should be sent to the HSE Manager within 24 hours of the incident.

SECTION 1 - ABOUT THE NEAR MISS / INCIDENT


Location / SITE :

Time : Date:

SECTION 2 - DESCRIPTION
(Briefly describe what happened and events leading up to the incident)

SECTION 3 - ABOUT THE PERSON COMPLETING THIS FORM


(Kindly provide your information below)

SECTION 4 - RECOMMENDATIONS TO PREVENT A SIMILAR INCIDENT

(Describe any actions which you have taken or recommend should be taken to prevent a similar incident in the future.)

PREVENTIVE ACTIONS
Describe actions which will be taken to prevent reccurance Deadline By Whom Closure

,,,,,,,,,,,,,
SECTION 5 - SEVERITY & INVESTIGATION RESPONSIBILITY
(To be determined by HSE Manager)
Nature Investigation Responsibility Name 1 Name 2 Name 3
Low Supervisor
SEVERITY Medium HSE Team
High Upper Management
INVESTIGATION TEAM
NAME SIGNATURE POSITION
INVESTIGATION REPORT REF #
INVESTIGATION REPORT REF #

Company where accident / incident / NM occurred Address

Department Date & Time

Name of Person involved Gender

Employment Category Employment Duration


Fulltime Regular Less than a year 1+ year
Part-time Temporary Less than 5 years 5+ years

Nature of Injury Numbers and names of others injured in same


accident

Root Cause(s) Severity


Fatality Serious
Injured First Aid
Minor Other

Phase of employee's workday at time of incident

During Rest Period Entering or leaving plant


During Meal Performing work duties

Describe how the incident occurred

Incident Sequence

Supervision at time of incident


Directly supervised Not Supervised Indirectly Supervised Not-feasible

Evaluation

HSE Dept. / Upper Management Signature

Report filled by: Designation Date


NEAR MISS / INCIDENT REPORT

NOTES
1. The site manager is responsible for informing the HSE department about any
incident / accident or near miss within 24 hours time.

2. All evidences must be secured immediately to avoid any tamper / alterations


to what really happened. If possible, it is the responsibility of the Site Manager
to secure all / any evidences within the first 30 minutes of the incident.

3. Attending to the injured must always be the first priority.

4. The HSE manager is responsible for selecting the investigation team after
carefully reading the initial report. The site supervisor, by default, must be
present during the investigation.

5. The selected investigation team will visit the site where the incident / near
miss occured and will gather all data which lead to the incident / near miss.

6. The evaluation of the investigation team must be signed by either the HSE
Department or the Higher Management.

7. A short briefing / meeting will take place at 10:00 AM the very next morning
in which all ECO Systems Pvt. Ltd. staff must be present. Atleast one Higher
Management should also be present in the meeting.

8. All key points must be noted down and explained completely to the
employees specially those who work on sites to avoid any of such incident or
near miss in the future.

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