Near Miss Reporting Form
Would you like to attach your name to this report?
Supervisor or Witness
Additional Contact Name
Additional Contact Email
Date of Incident
Time Reported to Work
Accident / Incident
Description of incident.
Is there a written SOP for the procedure being performed?
Were there any injuries?
Did anyone seek medical treatment as a result of this incident?
Was there any building damage?
Was there any equipment damage?
Type of Incident
Source of Incident
Why did it happen? Be specific in describing unsafe acts or conditions that contributed to the cause of the incident.
What corrective actions, if any, have been taken.
What corrective actions have been identified that still need to be implemented? Describe any obstacles preventing the implementation of identified corrective actions.
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