Title Page
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MADIC Engineer Name
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Date and Time of Incident / Near Miss
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Location of Incident / Near Miss
Report
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What were the weather conditions at the time of the incident/near miss
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Was the incident an Incident or a Near Miss
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Provide details of the Incident, INCLUDING PHOTOS
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If applicable, provide a POLICE crime/incident number
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Were any persons injured?
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Name of persons injured
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Details of injuries
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How were the injuries treated
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A near miss is defined by the HSE as any event that doesn’t lead to harm but does have the potential to cause illness or injury.
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Provide details and photo evidence
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Had you considered this near miss as a possibility during the initial risk assessment
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How do you think this can be avoided in the future
Witness
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Name, address and phone number of witness
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Signature of witness
Signatures
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MADIC Engineer
