Title Page

  • Site involved

  • Doc. No.

  • Report raised by

  • Add location
  • Reportee - Personnel/Patient/Public

  • Dept.?

Report Detail

Occurrences or Near Misses report

  • Location
  • Incident date (dd/mm/yyyy)

  • Time incident occurred

  • Name of Persons Involved Surname , First Name

Persons Involved (click as many as applicable)

  • Persons Involved (click as many as applicable)

  • Dept.?

  • Other

If Outside agencies/other, please state person(s) and reason for presence

  • undefined

Environmental Conditions

  • Conditions at the time of the incident

Incident classification - what happened? Click as many as applicable

  • No injury - near miss

  • Type of Injury

  • Other

Incident Hazard type - Occurred as a result/in relation to -

  • undefined

Outcome

  • Was it RIDDOR reportable?

  • HSE Form 2508 Type?

Harm received

  • Was there a physical injury?

  • Affected parts - Click as many as applicable

  • Please provide full details of what happened (please use people's initials instead of full names) Send any photo's under separate cover.

  • undefined

  • Please describe remedial actions to make safe/recurrence ( please use people's initials instead of full names)

  • undefined

Thank you for completing the report, please print a copy for your own records. The Quality Team.

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.