Accident Prevention – Near Miss Reporting Form

This form is to be used to report any incident that was a ‘Near Miss’.

This will help us prevent them becoming accidents. This form may also be used to report any general unsafe condition.

Name

Who did it invole?

Employee

Contractor

Member of the Public

Designation

Incident Location

Date of Incident

Time of Incident (24h)

The ‘Near Miss’ could have resulted in (tick as appropriate)

Personal Injury to Employee

Personal Injury to Third Party

Damage to the environment

Damage to Company Property

Damage to Third Party

Combination/other

Give a general description of the ‘Near Miss’ incident and any relevant information. (Please attached additional sheets if necessary).

Please give any suggestion for improvement regarding the incident described above.