SAFETY – HAZARD AND ENVIRONMENTAL MANUAL

REPORT ON NEAR-MISS OR UNSAFE ACT / CONDITION

Completion of this form reports a non-injury near-miss incident, an unsafe act, or an
unsafe condition. The purpose of this report is to inform fellow employees, clients, and
contractors of an incident, act, or condition that could, but did not, result in a personal
injury or a threat to health.
Zonge International guarantees that the completion of this form by an employee or
contractor will not influence employment decisions, pay rates, work schedules, or
performance reviews. Failure to report a near-miss or unsafe act or condition is a
violation of safety policy, however, and may result in termination of employment.
Upon completion, this report becomes an addition to the H&S Plan document for this
project.
Reported by: Signature:

Date:

Report acknowledged by: Signature:

Description of Incident, Act, or Condition:

Corrective Action or Suggestions to Avoid Recurrences:

2009-02-14 REPORT ON NEAR-MISS OR UNSAFE ACT / CONDITION Z04