Health Safety and Environmental Management Procedures Manual

Title: HS&EP 2 Issue 2 Revision: 01

Controlled Copy Page: 10 of 11

Hazard/Near Miss Report

Date: Location/Site: Report No.

Nature of hazard/near miss:

Any injuries/damage sustained? YES/NO

If so, give details:

Accident Report No.:

Raised by (print name): Signed:
Department: Signature of Supervisor:
Actions taken to make safe:

Does a hazard still exist? YES/NO

Further actions required/suggested:

Close out:

Report satisfactorily closed? YES/NO

Manager/Supervisor Signature: Date:

13 September 2004 OP 07 Briggs Commercial Limited

Form No. F002B