"Near Miss" Incident Report

** All Submissions Remain Anonymous **

Name: (This can be left blank if you choose to remain anonymous. If your name is recorded, it will be kept confidential.)

Date of Incident:

Time of Incident:

Incident Reported to:

Date of Incident Reported:

Time of Incident Reported:

Location of "Near Miss" Incident:

Names of Employees Involved:

Names of Witnesses:

What task or job was being performed?

Who was the supervisor at the time of the incident?

What caused the "Near Miss"?

For Administrative Use Only

Corrective Action:

Person Responsible for Corrective Action:

Date Corrective Actions Completed: