Incident, Accident, Near Miss & Good Catch Report

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Report Type & Reporter

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Type of report *

Date of event *

Time of event

Your name (reporter) *

Your email

Who is filling this in?

Completed by *

Completed by email

Put the employee's name above as the reporter. You and the reporter both get a copy.

01

MRDC Employee Involved

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Center this report on the MRDC employee(s) directly involved. List the primary person; add others under witnesses or notes.

Employee involved *

Job title / role

Department / crew

Supervisor

Contractor involved (if any)

02

What Happened

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Location / site / route

Activity at time of event

Severity & Injury

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Severity *

How serious was the outcome?

Was anyone injured? *

Injury / body part affected

Treatment level

04

Causes & Corrective Action

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Contributing factors / immediate cause

Immediate action taken

Corrective / preventive action recommended

Witnesses

Who has been notified?

05

Photos optional

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Attach any photos that help document the scene, hazard, or damage.

Add photos

06

Sign-off

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Reporter signature (name)

Reviewed with (supervisor)

Additional notes

Paper copy optional

If a paper form was filled in, scan it or take a photo of each page and attach it here (PDF or picture).

Attach paper copy

Report Type & Reporter

MRDC Employee Involved

What Happened

Severity & Injury

Causes & Corrective Action

Photos optional

Sign-off

Review Report