INCIDENT/NEAR MISS REPORT
(Check one):
___An incident is an event that caused injury to a person or damage to equipment, building or materials.
___A near miss is an event that could have caused injury to a person or damage to equipment, building or materials.
Person completing this form: _________________________ Date: ___________________
Name and job title of the employee involved in the incident/near miss: __________________
_________________________________________________________________________
Witness(es):__________________________________________________
Date of incident/near miss: ________________Time of incident/near miss: _______a.m./p.m.
Department and location where the incident/near miss occurred: _____________________________________________________________________
Employee's shift on the day of the incident/near miss (from) _____________ a.m./p.m. (to) _____________ a.m./p.m.
Did an injury occur? _____ Yes _____ No
Nature of the injury (strain, cut, bruise, etc.): _____________________________________
_______________________________________________________________________
Body part(s) affected: ______________________________________________________
Medical treatment required? _____ Yes _____ No
If yes, what type? _____ First aid on-site _____ Express care _____ Doctor _____ Hospital
Name of the facility, hospital or physician: ______________________________________
Was the employee hospitalized overnight as a patient? _____ Yes _____ No
Did the employee leave work early due to the injury? _____ Yes _____ No
If yes, what time? __________ a.m./p.m.
Date the employee returned to regular duty: _________________________
Date the employee returned with light duty restrictions: _________________
Describe the incident fully: (use back page if necessary or sketch on back if needed to clarify):
_____________________________________________________________________
_____________________________________________________________________
List all equipment, machinery, materials or chemicals the employee was using when the event occurred:
_____________________________________________________________________
_____________________________________________________________________
Identify the factors that you believe contributed to or caused the incident: ____________________________________________________________________
_____________________________________________________________________
Complete this section if an injury occurred or there was damage to equipment.
Were proper procedures being followed when the incident occurred? ____ Yes ____ No
If no explain: _____________________________________________________________
Was the employee wearing proper personal protective equipment? ____ N/A ____ Yes ____ No
If no explain: _____________________________________________________________
Are changes in equipment necessary to prevent reoccurrence? ____ Yes ____ No
If yes explain: ____________________________________________________________
Employee signature: _____________________________ Date: ____________________
Supervisor signature: ____________________________ Date: ____________________
Forward this form to the Human Resources Department as soon as possible following the incident or near miss.
Note: If an employee receives medical treatment from a doctor or hospital, additional forms will need to be filled out and forwarded to the HR Dept. along with the incident report so a workers' compensation claimed can be filed.
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