Near Miss Incident Information Report Form Page 2
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2Near 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.)
Probability/Severity Definitions
Catastrophic–I
Examples: Fatal or lifetime impairment, loss of sight or limb or permanent facility loss or events with multiple
critical incidents or > $1 million in financial impact.
Critical–II
Examples: Temporary impairment requiring rehabilitation and/or lifetime partial impairment, loss of use of
but not loss of a limb or facility not a total loss but must be rebuilt or events with multiple marginal incidents
or < $1 million and > $100,000 in financial impact.
Marginal–III
Examples: Injury requires a physician to treat a temporary impairment with complete rehabilitation possible or
sutures, clean fractures, injuries requiring transport to off-site medical facilities or events with multiple negligible
incidents or < $100,000 and > $1,000 in financial impact.
Negligible–IV
Examples: First-aid injuries not requiring medical professional intervention or < $1,000 in financial impact.
Witnesses
Name: __________________________________________________________________________________________________
First
Middle
Last
Address:_________________________________________________________________________________________________
City
State
Zip
Home phone: _____________________ Cell phone: ______________________ Work phone: _____________________________
E-mail: __________________________________________________________________________________________________
Others
Adult leader’s name: _______________________________________________________________________________________
First
Middle
Last
Address:_________________________________________________________________________________________________
City
State
Zip
Home phone: _____________________ Cell phone: ______________________ Work phone: _____________________________
E-mail: __________________________________________________________________________________________________
Information gathered at scene by: _____________________________________________________________________________
Contact information: ________________________________________________________________________________________
Return this completed form to your council’s designated user for entry into RiskConsole via MyBSA Incident Entry.
680-017
2010 Printing
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