NEAR MISS/ INCIDENT/ ACCIDENT REPORT 

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Person(s) Involved:

Name*

Details of Near Miss / Incident / Accident:

Severity:*
Treatment:*
This field is hidden when viewing the form
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*
Clear Signature
This field is hidden when viewing the form
This field is hidden when viewing the form
This field is hidden when viewing the form
Clear Signature
This field is hidden when viewing the form
This field is hidden when viewing the form

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

This field is hidden when viewing the form
Clear Signature
This field is hidden when viewing the form