Near-Miss and Incident Report
Use this form to report hazards or conditions that have the potential to cause an accident, injury, or illness in the workplace.
Your Manager
*
Department
*
Incident Details
Date of Incident
*
-
Month
-
Day
Year
Date
Time of Incident
Hour Minutes
AM
PM
AM/PM Option
Location
*
Specific Area
Conditions (Mark all that apply)
*
Near-miss
Safety Concern
Other
Incident Description, Concerned Suggestion, or Other
*
In as much detail as possible, describe the potential incident / hazard / concern and the possible outcome.
Root Cause / Corrective Action
*
Describe corrective measures taken to address immediate hazards related to the incident.
Relevant Pictures
Upload Images
Drag and drop files here
Choose a file
Add any relevant images related to the incident or near-miss
Cancel
of
Your Name
*
Date Reported
*
-
Month
-
Day
Year
Date
Signature
*
Submit
Should be Empty: