Near-Miss Report Form
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1NEAR-MISS INCIDENT/ACCIDENT REPORT FORM
Forward to Local Safety Committee
1. Name of Person involved ( Last, First, Middle Initial )
2.Title of Person involved
3. Department
4. Contact Phone Number (s)
5. Witness (Name & Phone # )
6. Date and Time of Incident/Accident
7. Near-Miss Location Site of incident/accident (Bldg. Name, Room #, Stairs, Hallway, Etc.) If outside of building, give
location in reference to nearest building, e.g.
Date:__________________________
___________________________________________________________________
___________________________________________________________________
AM______________________
___________________________________________________________________
PM_______________________
8. Near-Miss Description (Describe fully, the protocol/procedures being followed including all substances, equipment, and machinery being used which was related to the
near-miss. Use additional sheets if necessary.)
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
9. Corrective Actions (What should be done or what has been done to prevent recurrence of the incident/accident? e.g. employee training, Change of procedures,
purchasing of equipment, etc.)
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
10. Miscellaneous Information ( Provide any other information or recommendations which you feel are pertinent to this incident/accident)
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
DOC 1.3.3 (Attachment) Workers’ Compensation – Revised 09/28/10
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