SSCG ACCIDENT,INJURY,NEAR MISS REPORTING
 

1. Please complete all the boxes in this form
Person Reporting the incident *

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2. Injured Persons Details *

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3. Injured Persons Employment Status *

 

4. Summary of Event
i.e a brief description of the facts of what happened *

 

5. Is this a near Miss *

 

6. is this a dangerous occurance *

 

7. Are you reporting an injured person *

 

8. is this an environmental event *

 

9. was the location SSCG Property *

 

10. Type of injury(s) sustained *

 

11. Action Taken *

 

12. What first aid was administered *

 

13. Did the person die as a result of the injury or injuries *

 

14. if No did the injuries prevent the individual from carryng out their routine work for more than 7 days *

 

15. was the individual taken to hospital *

 

16. where was the incident reported to *