Close Call Report – Pendersons Staff Intranet

Close Call Report Form

Pendersons Group
Pendersons House
Pleasant Street
Burslem
Stoke On Trent
ST6 3DL

This form is for reporting Close Calls -

REMEMBER TO TAKE PHOTOGRAPHS IF YOU CAN - YOU WILL HAVE THE OPPORTUNITY TO UPLOAD THEM LATER

In addition to reporting the call via this form you should report the Close Call to your supervisor and/or site manager as soon as safe and possible, you may stop someone from being injured.

Company Division *

What was the lighting condition at the time? (Choose) *

Weather Conditions at the time (Choose) *

What Type of Close Call is this? *

On what date did it happen? *

Time *

Who Were You Working For? Who Were You Working For?

Enter Location / Site *

Describe what you have seen - (Give as much detail as possible.)

Describe what Could have happened *

Describe anything that could have caused damage to the infrastructure

Describe what were you able to do about it? *

Describe what you did to make it safe?

You Indicated that this is a Positive report,

Describe the good practice observed

Name

eMail Address so we can keep you informed about the Close Call

Your Contact Phone Details (In case we need to discuss the Close Call with you).

If you have taken any photo's of the Close Call, please upload them here.

Maximum file size: 33.55MB

Reporting of Close Calls/Good Calls is a key safety step in the prevention of incidents and accidents.

All of us have a part to play in ensuring ourselves and others get home safe every day without injury and we encourage that you identify and raise close and good calls.

For a reminder A Close Call is defined as anything that has the potential to cause harm or damage.

If you are human, leave this field blank.