NEAR-MISS REPORT FORM

INSTRUCTIONS

Use this form to report hazards or conditions that have the potential to cause an accident, injury, or illness in the workplace. Once complete, please submit this form to:

INCIDENT DETAILS

DEPARTMENT	DATE OF INCIDENT	TIME
LOCATION	ROOM / SPECIFIC AREA
CONDITIONS mark all appropriate
NEAR-MISS	SAFETY CONCERN	SAFETY SUGGESTION	OTHER describe, below
“OTHER” CONDITION DESCRIPTION
TYPE OF CONCERN mark all appropriate
UNSAFE ACT	UNSAFE CONDITINON OF AREA	UNSAFE CONDITION OF EQUIPMENT
UNSAFE USE OF EQUIPMENT	OTHER describe, below
“OTHER” CONDERN DESCRIPTION
INCIDENT DESCRIPTION In as much detail as possible, describe the potential incident / hazard / concern and the possible outcome.
SAFETY SUGGESTIONS Describe corrective measures taken to address immediate hazards related to the incident.
NAME optional	EMPLOYEE ID optional	DATE REPORTED
PHONE optional	EMAIL optional

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