Quench Canada- Incident/Near Miss Report

Incident / Near Miss Report

Please fill out one form per unit.
Date Submitted

MonthDayYear
Event
An incident is an event that did cause 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.
Form Initiator
Employee
Manager
Witness(es)
Date of Event

MonthDayYear
Date
Time of Event

Hour Minutes

AM/PM Option
Date Reported

MonthDayYear
Date
Location where event occurred
Start of shift on day of event

Hour Minutes

AM/PM Option
End of shift on day of event

Hour Minutes

AM/PM Option
Full description of event*
List all equipment, machinery, materials or chemicals employee was using when event occurred*
Identify factors that you believe contributed to or caused the event*
Nature of injury (strain, cut, bruise, etc.) *
Body parts affected*
Medical treatment required:

NoneFirst AidEmergency TransportDoctor or Hospital
Name of Hospital or Attending Physician
Was the employee hospitalized overnight as a patient?

YesNo
Did employee leave work due to injury?

YesNo
If Yes, at what time?

Hour Minutes

AM/PM Option
Date of return to regular duty

MonthDayYear
Date
Add photos to support each of the above*

Cancelof
Complete this section if an injury occurred or there was damage to equipment
Were proper procedures being followed when incident occurred?

YesNo
If No, explain:
Was employee wearing proper personal protective equipment?

YesNo
If No, explain:
Are changes in equipment necessary to prevent a recurrence?

YesNo
If Yes, explain:
Employee Signature

Clear
Manager Signature

Clear
Submitted by
Should be Empty:

Incident / Near Miss Report