Accident/ Incident/ Near Miss Form

Welcome to the Accident/ Incident/ Near Miss reporting page for Paragon Traffic Management. This page is exclusively for our employees to report any incidents that occur during work. We take all incidents seriously, whether it's a minor near miss or a major accident. Please fill out the form below with as much detail as possible. Your report will help us investigate the incident and prevent future incidents. All reports will be kept confidential and only shared with those who need to know. Thank you for your cooperation in helping us create a safe workplace.

Your name:

Contact number:

Date of Near miss/ incident, accident:

Time of Near miss/ incident, accident:

You are reporting a:
AccidentIncidentNear Miss
Employee:

Client:

Contractor:

Other:

TM Op Name:

Confirm you are the TM Op:
YesNo
Full site address:

Severity:
FatalSerious harmMinor harmNo harm/ Near miss
Treatment:
NoneFirst aidH&CCDoctorHospital
What treatment was given:

Who Gave The Treatment:

Describe What Happened:

Contributing Factors:
Operating without authorityDefective tools/ equipmentUsing unsafe equipmentUnsafe conditionsNot wearing PPEHousekeepingUnsafe positioningUnprofessional behaviourEnvironmental conditions

Describe The Cause Of The Near Miss/ Incident/ Accident: