POTENTIAL INCIDENT/NEAR MISS/INJURY FORM
This form should be used in reporting the incidents at our sites and offices. At Questworks we believe in ZERO HARM and SAFETY FIRST. This information will not only help one site but it will prevent future incidents from becoming an injury.
Email address *
I am reporting: *
Have you told your supervisor/PM about this injury? *
QUESTWORKS SITES *
Location of the place/ where exactly did it happen?
DESCRIBING THE EVENT
What led to the Event?
Attach Image (if any)
What could have been done to prevent this Event? *
What part of the body was injured?
If it is a near miss or PI, how would you have been hurt?
Immediate action taken? *
Required
Any recommendation?
Incident date *
MM
/
DD
/
YYYY
Submit
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