Title Page

  • Site

  • Report Date

  • Prepared by

  • Location

Employee Details

  • Name

  • Address
  • Date of Birth

  • Gender

  • Phone Number

Employment Details

  • Job Title

  • Employment Status

Accident/Near Miss Details

  • Date & Time

  • Hours at Work

  • Accident Type

  • Treatment Given

Injury Details

  • Nature of Injury

  • Mark Injuries

  • Where did the Accident/Near Miss Happen?

  • How did the Accident/Near Miss Happen?

  • Was the person trained for the task they were doing?

  • Was a vehicle involved?

  • Type of Vehicle

  • Was a significant hazard involved?

  • What was the significant hazard?

  • Is the hazard on the hazard register?

  • How serious could the injuries have been?


  • What happened?

  • Doctor visit is required?

  • Initial Needs assessment

Action Plan

  • Add steps to prevent a similar event from happening. Add action details in the paperclip icon.

  • Action Plan
  • Action Plan Summary


  • Worker

  • Health & Safety Manager

  • Management

  • Treating Doctor

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.