Near-Miss Incident Report Form NEAR MISS ~ INCIDENT/ACCIDENT REPORT YOUR NAME * DATE * INCIDENT Location/Site * TIME 121234567891011 : 0030 AMPM Site Supervisor * Please SelectASHASCOTTJESSE INJURED PERSON IS: No Person Employee Site worker Public EVENT TYPE: Property damage Injury Illness Near miss (Go to ‘what happened’ ) PARTS OF BODY INJURED: WHAT HAPPENED : * WHAT CAUSED THIS TO HAPPEN? : WAS A SIGNIFICANT RISK INVOLVED? Yes No IF YES, WHAT WAS THE SIGNIFICANT RISK? IS THE RISK ON THE RISK REGISTER? Yes No Your Signature signature keyboard Clear Submit If you are human, leave this field blank.
