Near Miss Incident Report Form

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:

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