Information
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Incident Report No.
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Conducted on
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Employee Name:
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Instructions:
1. Required to be completed when you experience a Safety Near Miss in the workplace
2. To be completed in full and emailed to supervisor and the Safety Director -
Date & Time of Near Miss:
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Location of Near Miss. If customer site, please provide address
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Select the category the near-miss most relates to:
- Fall from height
- Trip / Fall on same level
- Fall from equipment
- Hazardous Manual Handling
- Electric Shock
- Caught between/underneath
- Hazardous Substance
- Falling object
- Other
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Describe how the Near Miss occurred (include the body part and type of pain):
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Describe what lead up to and caused the Near Miss. Identify root causes:
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What was learned and changed due to the Near Miss?
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Photo/s that can help explain the what, where, why, or the possible injury:
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Name and Signature (optional)
