Form – DPL Group

Form

Digital IR2 Near Miss Potential Incident Form

Comments

This field is for validation purposes and should be left unchanged.

Use this form to submit NM/PI's observer during work activity.

Definitions, near misses, incidents that under slightly different circumstances could have caused injury e.g. materials falling from a scaffold, potential incidents, unsafe practices or hazardous situations that could result in an incident e.g. a trailing cable presenting a trip hazard.

Please upload supporting photos to this form.

When you submit this form, it will NOT automatically collect details such as your name and email address unless you provide this yourself in the relevant fields.

1. Please state the date of the NM/PI

2. Which DPL Group Division?(Required)

3. Client Name(Required)

4. Location (Town/City)(Required)

5. Who is the Principal Contractor?(Required)

5.1 Please specify name of Principal Contractor if Other was selected in 5.

6. Subcontractor name (if none, enter N/A)

7. Name of person involved (optional)

First Last

8. What is the likely cause of the potential outcome?(Select the most appropriate)(Required)

9. What was the potential outcome?(Select the most appropriate)(Required)

9.1 Please specify outcome if Other was selected in 9.

10. What is the probable cause of the NM/PI?(Required)

Please select the most appropriate

10.1 Please specify cause if Other was selected in 10.

11. Name of person reporting(Required)

First Last

12. Email address(Required)

13. Additional comments and corrective action (e.g. reporting the hazard to the line manager)(Required)

14. Upload image or file to support this report.

Drop files here or

Max. file size: 2 GB.

15. Please prove you are human.