Accident Incident / Near Miss Report

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.