Near-Miss Incident Report Form

Near-Miss Incident Report Form
A near-miss is a potential hazard or incident in which no property was damaged and no personal injury was sustained, but where, given a slight shift in time or position, damage or injury easily could have occurred. Near-misses also may be referred to as close calls, near accidents, or injury-free events. For the sake of a safe work environment, ISD#31 asks that all employees report and correct any of these potential hazards immediately.

Please complete this form to report near-misses and assist in preventing future incidents and making ISD#31 a safer workplace.

Please note that this form does not take the place of a work order submission to report unsafe conditions.
Type of Concern*

Safety Ideas /SuggestionsUnsafe ActUnsafe Use of EquipmentSlippery SurfaceOther (please describe)
Building or School*
Date of Incident*

MonthDayYear
Time of Incident*

Minutes

AM/PM Option
Witnesses (optional)
Describe the potential incident / hazard / concern and possible outcome (be detailed): *
Recommendations / Steps to take to prevent a similar incident:
Name (optional)

First NameLast Name
Date Reported*

MonthDayYear
If you have any questions or concerns, please contact Bryan Johnson at bryan_johnson@isd31.net or 218-333-3149.
Should be Empty: