Hazard/Near Miss/Injury

Please submit for notification of all hazards or near misses, and injuries.

PLEASE INDICATE REASON FOR THIS FORM

HAZARD NOTIFICATION - something that you have seen or heard about and you think it could CAUSE an injury or fatality.

NEAR MISS NOTIFICATION - something that you saw that could have been an injury or fatality - it nearly happened.

INJURY - PERSON HAS BEEN INJURED - something that happened and someone was injured.

Name of Person filling in this form

First Name

Last Name

Email

Phone

(###)

###

####

Location

Arataki Community Centre

Outdoors - car park/ Skate park/fields

Church Office

Other

More Detail on Location

Date of Incident

MM

DD

YYYY

Date form completed

MM

DD

YYYY

Please fill in either the hazard notification, near miss, or injury report form below and submit.

Hazard Notification

WHAT HAVE YOU OBSERVED?

WHAT DO YOU THINK WOULD CAUSE INJURY OR INCIDENT?

WHAT DO YOU THINK WE SHOULD DO TO STOP THIS HAPPENING? (IN YOUR OPINION)

FURTHER COMMENTS

Near Miss Notification

Did anyone get hurt? COMPLETE THE PERSON HAS BEEN INJURED SECTION

WHAT IS A NEAR MISS?

Near misses are a subset of incidents where no one got hurt, but only by a pure stroke of luck. In a near-miss, someone was a hair's breadth away from getting injured. But near-misses may be more difficult to distinguish, but they are crucial to pinpointing health and safety risks no one was previously aware of. If you're having trouble determining whether an event was an incident or a near-miss, all you need to do is consider the following:

Was this an unexpected or adverse incident?
If the conditions were slightly different—say, if someone was standing only a few centimeters to the side—could anyone have gotten hurt?

WHAT HAPPENED? WHAT HAVE YOU OBSERVED?

WHAT DO YOU THINK CAUSED OR CONTRIBUTED TO THE INCIDENT?

WHAT DO YOU THINK COULD STOP THIS HAPPENING?

FURTHER COMMENTS

DATE INCIDENT HAPPENED

MM

DD

YYYY

TIME INCIDENT HAPPENED

Hour

Minute

Second