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:*
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*
Signature
Signature

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

Signature*