Incident, Near Miss and Hazard Report Form
v2.2
Purpose. Used by any staff member to report an injury, exposure, spill, equipment failure with safety consequences, near miss or hazard in the laboratory, materials hall, vehicle or field.
1.When to use this form
Complete this form for any injury or illness, chemical or biological exposure, spill, fire, equipment failure that endangered someone, near miss or hazard. Submit it to your section manager before the end of the day. For serious injury, get help first and complete the form afterwards.
2.What happened
Describe the event in the order it happened, in plain words. Name the chemical, organism, equipment or vehicle involved and what task was being performed. Attach the safety data sheet reference if a chemical was involved.
3.Exposure details
For chemical or biological exposure, record the substance, the route (skin, eyes, inhalation, ingestion or needlestick), the duration, the first aid given and whether the person was referred for medical assessment. The Quality Manager will decide whether health monitoring is required.
4.Immediate action
Record what was done to make the area safe, including spill clean-up, isolation of equipment or evacuation, and whether the hazard remains.
5.What happens next
The section manager enters the report in the WHS incident and hazard register. The Quality Manager decides whether an investigation is needed and whether the event is notifiable to the safety regulator. You will be told the outcome.