Near Miss Incident Information Report
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1
2Near Miss Reporting Tool
(A near miss does not result in injury, illness, or damage, by definition, but it had the potential to do so.
This form is a tool to gather information. If an injury has occurred, use the incident reporting tool.)
General Incident Details
*Required Fields
*Incident Date: ________________________________ Incident Time (in 24-hour format): ______________________________________
*Report Date: _______________________________________________________________________________________________________
Date Reported to Council/BSA Location: ______________________________________________________________________________
Reported by Name: _________________________________________________________________________________________________
Reported by Primary Phone: ______________________________ Reported by Secondary Phone: _____________________________
Reported by Email: __________________________________________________________________________________________________
Reported by Address: _______________________________________________________________________________________________
Reported by City: _________________________________ Reported by State: __________ Reported by Zip Code: _______________
*Council/BSA Location: ______________________________ *Location of Incident: ___________________________________________
Specific area where incident occurred: ________________________________________________________________________________
Incident Address: ___________________________________________________________________________________________________
Incident City: _____________________________________ *Incident State: ______________ Incident Zip Code: ___________________
*Description of Incident (clear/concise/complete facts):
Was an Agency or Authority Notified?
❏ Yes
❏ No
Whom: ____________________________________________________
Near Miss Details
Adventure/Program/Event: ____________________________________________________________________________________________
General Classification (Cub Scout/Registered Leader/etc.): ______________________________________________________________
*Lessons Learned (what could be done to prevent future occurrences):
Severity Rating:
❏ Catastrophic-I
❏ Critical-II
❏ Marginal-III
❏ Negligible-IV
❏ Unknown
Witnesses
(Use back of form to record other details and witness contact information)
680-017
2017 Printing
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Parent category: Business