Incident and Near-Miss Report Form - RCI

  • Incident and Near-Miss Report Form - RCI

  • Person(s) Involved:

  • Format: (000) 000-0000.
  • Department / Section:*

  • Details of near miss / incident / accident:

  • Date/Time*
     - -

  • Severity:

  • Severity:*

  • Treatment:

  • Treatment:*

  • Description of what happened:

  • Preventive/Corrective Actions taken:

  • Significant hazard

  • Has a significant hazard been identified?*
  • Chance of the near miss, incident or accident reoccurring:*

  • Copies or parts of this Procedure are considered Uncontrolled Copies when printed unless otherwise specified.


    Modification, reproduction, and/or distribution of this document, in part or in full, without written authorization from Reza Chemical Industries is prohibited.

  • Should be Empty: