Incident and Near-Miss Report

In the event of an incident or near-miss while conducting Oppure Oil business, please complete this form right away. Your Supervisor will follow up with you at the office.

About the person reporting the incident:

First Name

Last Name

Phone Number

Email Address

Date and Time of Incident

Date and Time of Incident Report

Incident Description

Did anyone witness the incident?

(If Yes, please complete the additonal witness information)

Yes

About the witness:

Witness Full Name

Witness Phone Number

Witness's Incident Description

Follow up (To be hand completed with Supervisor):

Was this incident preventable?

Yes

Suggested Corrective Action

Reporter Signature (to be hand completed)

Witness Signature (to be hand completed)

Supervisor Signature (to be hand completed)

Validate your submission