Safety Incident Reporting Forms by bmm18288


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  Near-Miss reports are intended as a means to quickly share information about incidents and near-misses within the PNL
  Team. This form is to be completed immediately after an observation or event.

  Guidance: Provide available facts. Do not speculate. Do not complete blanks that are not applicable. Do not include
  names of persons or companies or identify third parties.

  Incident Date:                                                             Person Preparing Report:

  Incident Time:                                                             Signature:

  City, State, Loc:                                                          Office Manager:

  PNL Office:

  Type of incident or significant near-miss/loss (check all that apply):

       Injury (including first aid or RSI)                                      Security Incident (theft, violence, kidnap, etc)

       Fire                                                                     Significant Near-Miss/Loss
                                                                                Describe POTENTIAL incident (e.g. serious injury,
       Spill/Release (any volume)
                                                                                fatality, major spill, etc.)
       Regulatory Action

       Property Damage                                                          Other (specify):

  Brief description of the following:

  Event: (Draw a sketch. It will help clarify.)                            Injuries, if they have occured:

                                                                           Responses which have taken place (e.g., first aid, medical
                                                                           visit, spill response, etc.):

  Sketch of Office Location:

                                                                           Corrective actions taken:

    Send to: Mike Bacsik | One Pointe Drive, Suite 320, Brea, CA 92821 | Phone: (714) 388-1800 Fax: (714) 388-1839 |

Version 1, 13JUN08

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