INCIDENT / NEAR MISS REPORT

Project:

Date:

Contractor:

No:

Location and Time

-

Task:

Date:
Time:

Stick

Criteria Involved
Personal protective equipment
Loading , moving materials
Support / hanging device
Security
Fire
Electrical connections
Machinery: welding, burning, rotating device, etc.
Chemical / corrosion
Others

Factual Statement

Immediate Action Required

Owner

Further action suggested

Consultant
Royal HaskoningDHV

Contractor

Name:
Position:

Name:
Position:

Name:
Position:

Date:

Date:

Date:

Date: June 21, 2004

Rev: 00

Code: ADM-00-04