Incident Reporting System

This report is for

Near Miss Incident

Safety and Health Concern

Safety and Health Incident/Accident

Suggestions, Requests and Corrective Action

Reported By: Include your full name, phone number and email address

Department

Describe Corrective Actions, Suggestions and/or Requests

Date and time of near miss incident, safety and health concern, or safety and health incident/accident

Location of near miss incident, safety and health concern, or safety and health incident/accident

Detailed description of safety and health concern: Include relevant information such as, but not limited to, number of employees exposed, frequency of employee exposure, and employee proximity to the safety and health concern (It is preferred that the information is provided by the affected employees):

Detailed description of near miss incident: Include relevant events leading up to, during, and after the near miss incident (It is preferred that the information is provided by an affected employee)

Description of near miss incident from an eyewitness: Include names of persons interviewed, job titles and date/time of interviews:

Detailed description of accident (Please attach an Accident Investigation Report)

Lists all Contractors involved in accident:

Recommended corrective action(s) to mitigate or abate safety and health concern

Recommended corrective action(s) to prevent future near miss incidents

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