Title Page

  • Site conducted

  • Classification

  • Conducted on

  • Prepared by

  • Location


Part A. General Information

  • Date and Time of Incident

  • Date and Time of First Report

  • Business Area (select one)

  • Specify Other Business Area

  • Product Type (select if applicable)

  • Department (Assembly/Rail/etc.)

  • Exact Location (Equip SAP #, Table #, Room, Pole #, etc.)

  • Category

  • Was work stopped due to a hazard?

  • Please provide details

  • Was anyone exposed to body fluids?

  • Who?

  • Accident Type (select all that apply)

  • Please specify Other Accident Type

Part B. Individual Involved

  • First Name

  • Last Name

  • Employee ID Number

  • Temp. Employee

  • Job Title

  • Shift

  • Supervisor

  • Time Employee Began Shift

Part C. Incident Details

  • Describe the incident fully. Include the events leading up to the incident, any equipment or substances involved, any injuries or damage sustained, and any other important details regarding the incident.

Part D. Injury/Illness Details If the incident was a near miss (no personal injury sustained), skip this section.

  • Nature of Illness/Injury: (select all that apply)

  • Please specify Other Nature of Illness/Injury

  • Body Part (select all that apply)

  • Please specify Other Body Part

Part E: Causal Factors and Associated Activities: (select all that apply) Contributed to the incident happening.

  • Process

  • Equipment

  • Environment/Work Area

  • People

  • Please list any others:

Part F: Details of First Aid Measures, if applicable (Band-Aid, wound care, hydrocortisone cream, ice, etc.)

  • undefined

Part G: Recommendations to Prevent Recurrence: If an engineer is the Person Responsible, include the Engineering Manager and Engineer in Near Miss email.

  • Tap "+"

  • Recommendation
  • What measures are being taken to prevent this incident from recurring?

  • Person responsible for action

  • Scheduled completion date

  • CI Card Submitted?

  • CI Card Number

Part H: Review

  • Supervisors: Please send this document to your Operations Manager and the Safety Department if there was an injury.

  • Completed By: (Signature)

  • Notes (EHS Internal Use Only):

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.