Incident, Near Miss and Environmental Event Report Form
v3.0
Purpose. Workers use this form to report any injury, near miss, hazard, property damage, spill or environmental event so that it is recorded in the Safety and Environment Register and investigated.
1.When to use this form
Complete this form for any event that hurt someone, could have hurt someone, damaged plant or property, or released fuel, oil, sediment or waste to the environment. Complete it before the end of the shift and give it to your supervisor. In an emergency, make the area safe and get help first.
2.Who completes it
The person involved or the person who saw the event completes the form. The supervisor reviews it, adds immediate actions and enters it into the register. The SHE and Certification Manager assigns an investigator for any injury, notifiable incident or environmental event.
3.Describing the event
Describe what happened in plain words, in the order it happened. Include the machine, tool or material involved, the weather and ground conditions if outdoors, and who was present. Do not guess at causes; the investigation will establish them.
4.Notifiable incidents
A death, a serious injury or illness or a dangerous incident such as a rollover, a fall of a tree onto a machine or an uncontrolled fire is notifiable. The supervisor must contact the SHE and Certification Manager immediately and must not disturb the scene except to help an injured person or make the area safe.
5.After the form is submitted
The supervisor will confirm the record number from the register with the person who reported it. The investigation findings and corrective actions will be shared at the next toolbox talk for the crew involved.