Near Miss Incident Information Report Form

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Near Miss Incident Information Report
(A near miss does not result in injury, illness, or damage by definition, but it had the potential to do so.)
Near miss incident date: _______________ Time: ________________
Reporting date: ______________________ Time: ________________
Council/BSA location: ______________________________________________________________________________________
Reporting person: __________________________________________ ❏ Leader
❏ Parent
❏ Other: ___________________
Contact information: ________________________________________________________________________________________
Location of near miss: ______________________________________________________________________________________
Specific area where near miss occurred:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Cause of near miss: ________________________________________________________________________________________
________________________________________________________________________________________________________
Activity at time of near miss: _________________________________________________________________________________
Program/event/adventure code: _______________________________________________________________________________
Description of the near miss (detailed):
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Did the near miss occur while transporting to/from an activity? ❑ Yes
❑ No
Potential severity:
❑ Catastrophic–I
❑ Critical–II
❑ Marginal–III
❑ Negligible–IV
❑ Unknown (See the back of this
sheet for definitions.)
Lessons learned (what could be done to prevent future occurrences):
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Witnesses (See the back of this sheet to enter.)
Return this completed form to your council’s designated user for entry into RiskConsole via MyBSA Incident Entry.

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