Safety Incident and Near Miss Report

Reporting Member First name

Reporting Member Last name

Incident Member First Name

Incident Member Last Name

Date and time of near miss or incident

Year

Month

Day

Time

HoursMinutes

Location of near miss or incident

Witness(es) of near miss or incident

Description of near miss or incident

Description of injury (if applicable)

Property Damage?

Yes

Description of property damage

Severity of incident or near miss (check all that apply)

1 - Near miss

2 - Minor Incident - Ex: First aid only injury.

3 - Minor Incident – Ex: Injury requiring medical treatment.

4 - Serious Incident – Ex: Fire, electrical contact, unconscious as a result of a concussion, fractured bone(s), third degree burns, permanent or temporary loss of sight, cut or laceration requiring treatment at a hospital, asphyxiation or poisoning.

5 - Serious Incident that resulted in a fatality.