Incident/Accident/Near Miss Report

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Client site

• Prepared by

• Location
  Address

Detail of Incident/Accident/Near Miss

• Nature:

  Select Incident Injury Near Miss Accident

  • Incident
  • Injury
  • Near Miss
  • Accident

• Date of Event

  Date

• Date reported

  Date

• Reported to

• Person involved:

• Address

• Phone number

• Date of Hire

• Supervisor

• Supervisor phone number

• Describe what happened

• Photos

  Media

• Voluntary Statement

  Media

• Weather Conditions

  Select Clear Cloudy Rain Windy Other

  • Clear
  • Cloudy
  • Rain
  • Windy
  • Other

• Witness

Injury Details (If applicable)

• Nature of injury

• Part of body injured

• Treatment Received

  Select First Aid Hospitalized Other Refused medical treatment

  • First Aid
  • Hospitalized
  • Other
  • Refused medical treatment

• Was machinery involved

• Action taken immediately after accident

• What action contributed to incident

• What corrective action(s) could have been taken or planned out to prevent reoccurrence