Free Near Miss Incident Report Form Template
Near Miss Incident Report Form
Please complete this Near Miss Incident Report Form Template to document and assess incidents that could have resulted in injury or damage but were narrowly avoided.
Date of Near Miss
Time of Near Miss
Description
Location
Name of Reporter
Position/Job Title
Phone number
Describe the Incident
Provide a brief description of what happened and how it occurred
What was the potential risk or injury that could have occurred?
Describe the potential consequences of the near miss
Were there any witnesses?
If yes, list names and contact information.
|
Witness Name |
Phone Number |
|---|---|
|
|
|
|
|
|
Immediate Actions Taken
What was done immediately after the near miss to prevent an incident?
Recommendations to Prevent Future Incidents
Any suggestions for corrective actions or improvements?
Reported By
Name:
Date:
Incident Report Templates @ Template.net
Thank you for submission!
We appreciate you taking the time to submit.
Create free forms at Template.net
