Near-Miss & Incident Report
A confidential near-miss and incident report form — type, sequence of events, contributing factors, root cause and preventive actions, filled out while the details are still fresh.
Near-Miss & Incident Report
PDF · 673 KB · 1 page
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It handles the full range: near-miss, first aid, recordable injury, property damage or vehicle. Capture who was involved and witnessed it, the task being performed, the equipment, and the contributing factors — PPE, procedure, equipment failure, communication, environment, fatigue.
There's space for the immediate action taken, a brief root cause and recommended preventive actions, with reporter and supervisor sign-off. It's marked confidential and notes that reporting near-misses is encouraged and won't be used for discipline — the only way you actually hear about them.
What's inside
- Incident type: near-miss, first aid, recordable, property, vehicle
- People involved and witnesses
- Sequence of events and task being performed
- Contributing-factors checklist
- Immediate action, root cause and preventive actions
- Reporter and supervisor sign-off