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Report Type:: Accident | Incident Investigation ReportNear Miss Report
Date of Report:
Time of Report:
Date of Accident | Incident:
Time of Accident | Incident:
Select the type of incident/accident that you are reporting to us:: AccidentIncidentMedical or Disease (COVID-19)Environmental DamageProperty DamageQuality
Employee Details:: First Name:
Last Name:
Date of Birth:
Worksite:
Supervisor Name:: First Name:
Last Name:
Describe the injury and/or body part injured.:
Estimated Severity of Injury:: Lost timeNo lost time
Treatment Details:: NoneFirst AidDoctor/ClinicHospital
Where did this accident/incident occur?:: Line 1:
Line 2:
City:
Country:
Australia
State:
Postal Code:
Describe what went wrong.:
Witness 1:: First Name:
Last Name:
Witness 2:: First Name:
Last Name:
Witness 3:: First Name:
Last Name:
Immediate corrective action taken to prevent danger to other employees. Describe actions taken.:
Who implemented the corrective action?:: First Name:
Last Name:
Is this accident/incident notifiable under the WHS Regulations 2012?:: YesNo
A notifiable incident/accident is: the death of a person; a serious injury or illness; COVID-19; dangerous incident.
What caused the situation to go wrong?:
What could have been done to prevent it going wrong?:
Recommendation to rectify this situation (1):
Date Recommended:
Person:: First Name:
Last Name:
Recommendation to fix this situation (2):
Date Recommended:
Person:: First Name:
Last Name:
Recommendation to fix this situation (3):
Date Recommended:
Person:: First Name:
Last Name:
Do you have further recommendations?:: YesNo
Please list further recommendations below. Make sure to identify the date and people associated with each.:
Is the Manager satisfied that all recommendations have been considered and implementation of approved actions to correct this are in place?:: YesNo
Date of Near Miss Report:
Time of Near Miss Report:
Date of Near Miss:
Time of Near Miss:
Personal Details:: First Name:
Last Name:
Worksite:
Describe where and what happened:
What could have been done to prevent it from going wrong:
What is the cause, if determinable, of the incident:
What course of action may be taken to prevent this situation from reocurring:
Declaration:: The information I have provided in this report is true and correct

Call Us08 8531 1733

Email Usadmin@mtesa.com.au

Reach Us6 Seventh St, Murray Bridge SA 5253

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Phone: 08 8531 1733

Fax: 08 8531 0474

ABN: Contact our Senior Field Officers: Mick Law (M) 04

Address: 6 Seventh St, Murray Bridge, South Australia, Australia, 5253

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