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Incident or Near Miss Reporting

Date and time of incident*

Day

Month

Year

Time

:HoursMinutes

Location (site/room/or online setting)*

Name(s) of people involved*

Email*

Type of Event

Accident

Injury

Illness

Near Miss

Property Damage

Other (please specify)

Provide a clear, factual description of the incident or near miss*

Immediate Actions Taken*

First aid given

Emergency services called

Equipment isolated/area made safe

Supervisor/manager notified

Other

Details of actions taken (e.g. who provided first aid or time emergency services were called)

Approximate number of individuals affected*

If witnesses, please enter contact details

What do you think caused the incident or near miss?

What steps have been or will be taken to prevent recurrence?

Witness statement taken?

Signature*

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