Near-Miss/Incident Report Form

This form should be completed by any employee who witnesses a near-miss or incident, such as collapsing shelves, items falling from height, charred or burnt electrical equipment or furniture, or slip on a slippery surface, where he person did not actually fall. Heads of Departments may complete the form on behalf of the person who witnessed the near-miss or incident.

Type of Report
Name Name First Last
Job Title
Date of near-miss/incident Date of near-miss/incident / DD / MM YYYY
Location
Approximate time of near-miss. Approximate time of near-miss. : HH MM AM/PM
Immediate action taken by the person reporting the near miss/ incident.

Did they stop the activities?, Did they action and then inform their line manager
Please describe the near-miss which you witnessed below.
Photos of Near Miss/ Incident
Names of any other witnesses
Name of the manager who was informed about the near miss/ incident. Name of the manager who was informed about the near miss/ incident. First Last
Any Recommendations from the person reporting the near miss/ incident?

Any recommendations from wittiness to be noted to assist with the investigation.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date of signature. Date of signature. / MM / DD YYYY