Near Miss Incident Report
Section 1 of 3 · 5 questionsDetails Of Person Reporting
First Name
Surname
Category of Person – staff, student, contractor or visitor
If other, give more details
Name of the contractor (if applicable)
Section 2 of 3 · 2 questionsGeneral Information
Date and time of the Incident.
Location (please be as accurate as possible).
Section 3 of 3 · 6 questionsIncident Details
Description of the Incident
Describe what happened?
What immediate actions were taken at the time?
List additional actions which could be taken to prevent a similar occurrence?
Photograph(s) of the area and/or results of the near-miss or incident
Additional comments / observations
Checklist by GoAudits. This checklist is an example: we do not guarantee compliance with the laws applicable to your territory or industry. Seek professional advice to adapt it to your workplace or jurisdiction.
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