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Near Miss / Incident / Accident Report & Investigation Form

Person(s) Involved:

Name(Required)

Details of near miss / incident / accident:

MM slash DD slash YYYY
Time(Required)
:
Severity:
Treatment:
Chance of the near miss, incident, or accident recurring:
Corrective Action: (What will be done to minimize the risk of this happening again)
Action
By Whom
Completed
 

Person in control of the workplace:

Name(Required)
MM slash DD slash YYYY

Near Miss / Incident / Accident recorded and all corrective actions are completed:

MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.