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Name of Person Completing Form (Last, First, Middle Initial). 4. 10: Near-Miss Location – Site of Incident (Building name, Room No., Stairs, Hallway, etc.)
To be completed by an employee or contractor reporting a hazard or near miss. ** Insert Manager's name and contact details before proceeding **. Position:.
Non-Injury and Near-Miss Incident Reporting Form. Instructions: • If personnel were injured during the incident, do not use this form, use 'Supervisor's
If you are reporting a non-injury Near Miss incident, skip to Item 27. . Sign and date the form, and submit all documents to the affected or injured / ill employee's
This form should be completed by any employee who witnesses a near-miss incident, such as collapsing shelves, items falling from height, charred or burnt
The reason for investigating an incident or near miss is to determine: the cause An incident /near miss investigation report should answer the WHO, WHERE,
The form must not be used for reporting accidents where either people or buildings were injured or damaged. The University Accident and Dangerous Incident
Near Miss / Incident / Accident. Report & Investigation Form. This form must be completed with corrective actions and Manager's comments before returning it to
ELECTRIC SHOCK AND/OR INCIDENT REPORT. for the Office of the . What other near misses or similar accidents have occurred? What safety rules
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