D.P.S.I.

Near-Miss & Incident Report

Near Miss Report & Incident Report

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Information

Document No.
Audit Title
Client / Site
Conducted on
Prepared by
Location
Personnel

Parties involved
Select date
Location of Near Miss / Incident
Pictures
Type of Incident or Significant near-miss
- Injury(First aid)
- Property Damage
- Significant Near-Miss/Loss
- Fire
- Spill/Release
- Regulatory
- Other
If other(specify)
Description of Incident or Near Miss
Sketch of scene
Action Items Required
Safety Department

D.P.S.I.

Near-Miss & Incident Report

Near Miss Report & Incident Report

Use this Template

Print as PDF

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.