"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: