REGEX Near Miss Report Form

REGEX Near-Miss Reporting Form
Date

MonthDayYear
Date
Time
Station
Location of Incident: Address:
Address
City
State
Zip Code
Name
Contact Number
Email
example@example.com
Job Title
Description of Near-Miss Incident: (Provide a detailed description of the near-miss incident Include information about what happened the sequence of events and any contributing factors.)
Witnesses: (List the names and contact information of any witnesses to the near-miss incident.)
Name
Contact Number
Address
Email
example@example.com
Name
Contact Number
Address
Email
example@example.com
Contributing Factors: (Identify any contributing factors that may have led to the near-miss This could include environmental conditions, equipment issues, human factors, etc.)
Actions Taken: (Describe any immediate actions taken to mitigate the situation or prevent further harm.)
Recommendations: (Provide recommendations on how to prevent a similar incident in the future This may include changes in procedures additional training or modifications to equipment.)
Additional Comments: (Include any additional information or comments relevant to the near-miss incident.)
Acknowledgment: I understand and acknowledge that the information provided within this near-miss report form is an honest and accurate account of the case to the best of my knowledge. I understand that this is an official report and that failure to cooperate with any further investigation and resolution of this matter could result in disciplinary action up to and including termination. Furthermore, I acknowledge that the falsification of information could also result in disciplinary action up to and including termination.
Employee Signature

Clear
Date

MonthDayYear
Date
SupervisorManager Signature

Clear
Date

MonthDayYear
Date
Please return this completed form to the Safety & Risk Management Team within 24 hours. If further investigation is required, the appropriate personnel will be in touch. Thank you for your prompt attention to this matter.
Should be Empty:

REGEX Near-Miss Reporting Form