Incident or Near Miss Report
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Mountain Operations
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Merrijig
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Incident or Near Miss
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Incident
Near Miss
Details of Person involved in Injury or Illness or Incident or Near Miss
Employee or Guest or Contractor Name
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Contact Number
Home Address
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Male
Female
Date of Birth
Employment or Relationship Status to Organisation of Injured Party
Full Time Employee
Part Time Employee
Seasonal Worker
Contractor
Guest or Visitor
Position if Employee
Injury or Illness or Incident or Near Miss Details
Date of Occurrence
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Time of Occurrence
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Description of Occurrence
Complete if incident occurred during lesson or chairlift activity
Instructor Name
Level of class provided
Lift Name
Loading or Unloading
Loading
Unloading
Details of Incident
Type of Incident
Safety
Environmental
Property Damage
Other
If other type please specify
Exactly where did the incident occur
Attach diagram or map if relevant
Upload photos if relevant
Direct Cause of Incident
Fall of person
Falling object
Explosion or implosion
Step on or strike object
Caught in or between objects
Slip on ice or snow
Near miss
Manual handling injury
Trip or other slip
Slip due to substance spill
Non person related injury such as property or equipment damage
Struck by object such as knife or tools etc
Extreme temperature exposure
Electrical current
Harmful substances
Radiation
Exposure to noise
Spill of substance
Other environmental
Type of Injury
No injury reported
Fractures or dislocations
Sprains or strains
Concussion
Lacerations or open cuts
Frostbite or hypothermia
Illness
Occupational overuse or injuries
Poisoning or toxic effects of substances
Confusions or bruising or crushing
Braises or abrasions
Pre existing condition
Burns and scalds
Puncture or penetration
Wounds
Amputations
Electric shock
Bites or stings
Other
Not applicable
Environmental and Terrain and Surface Conditions
Low light
Ice on surface
Snow on surface
Slippery surface
Below freezing
Hot temperature
Steep slope
Terrain park
Snowing
Raining
Roadway or pathway
Outdoors
Indoors
Unknown
Other
Not applicable
Bodily Location
Eye
Ear
Face
Head other than eye or face
Shoulder
Neck
Arm
Hand and fingers
Hip
Trunk
Back
Psychological
Internal organs
Feet or toes
Leg
General or unspecified location
Other
Not applicable
Agency or Cause of Incident
Animals
Chemicals
Physical environment
Insects
Floors and passageways
Stairs
Fixed or mobile plant or machinery
Surface
Non powered hand tools
Road transport such as cars and bikes
Snow transport such as Skidoo
Equipment including powered tools
Syringes
Biological agencies
Manual handling
Person or people
Slips or trips or falls
Inadequate training
Foreign bodies
Objects
Other agency
Not applicable
Ski or snowboard activity
When did the incident occur
During work time
During instruction such as skiing or skating
Journey to or from work
During break from work
During activity such as skiing or skating
Other
After the incident did the person
Return to work
Go home
Return to activity
Go to the hospital or doctor
Other
Was First Aid received
Yes
No
Details of Witness to Incident
Name of Witness
Contact Number of Witness
Address of Witness
Position of Witness
Employee
Guest
Contractor
Managers Comments and Further Actions
Comments
Further Actions Required
Manager Sign off
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