HAZARD / NEAR MISS / INCIDENT / COMPLAINT

This report must be completed by workers or any visitor when a hazard is identified and
either its eliminated or it cannot eliminate at that moment. Also the report has to be
completed when an accident/incident occur, or a near miss happened or you have any
complaint regarding something.

The report must be submitted to the Safety Manager ASAP for mitigation control.

HAZARD NEAR MISS INCIDENT COMPLAINT

DATE: TIME:
LOCATION:
DESCRIPTION OF HAZARD/NEARMISS/INCIDENT/COMPLAINT:

IMMEDIATE ACTION TAKE:

THIS PORTION HAS TO BE COMPLETED BY SAFETY MANAGER

ACTIOIN TAKEN TO INVESTIGATE THE CAUSE OF THE PROBLEM

CAUSE OF THE PROBLEM

ACTION REQUIRED TO PREVENT THE CAUSE AGAIN

ALL ACTIONS COMPLETED AND ISSUE CLOSED

SIGNATURE:________________ DATE:__________________