• Incident Report

  • Please select the group at the time of the incident:*
  • What type of report are you submitting?*

  • What is a Near Miss?

    A near miss is an event or situation that had the potential to result in injury, harm, property damage, service disruption, or a safety incident, but was avoided before an actual incident occurred. Near misses may be prevented through staff intervention, existing safety measures, or chance.

    The purpose of completing a Near Miss Report is to identify hazards, risks, and process gaps so that corrective actions can be taken to prevent similar incidents in the future. Reporting near misses supports a proactive approach to safety, continuous improvement, and the well-being of students, participants, staff, practicum students, volunteers, and visitors.

     

    Examples:

    During classroom activities, a student nearly tripped over a laptop charging cord that was stretched across the floor. Staff noticed the hazard and secured the cord before any injury occurred. No students were harmed, and learning continued safely.

    During a group activity, a participant became upset and nearly threw a chair across the room. Staff quickly redirected the participant and helped them calm down. No one was injured, and no property was damaged.

    During a transition, a student was accidentally left unattended due to a miscount. Staff quickly realized the discrepancy and found the student safe and unharmed. Although no harm occurred, the situation presented a potential safety risk and should not have happened.

    A parent/guardian provided medication in incorrect or mismatched packaging, creating a risk of the student receiving the wrong medication or dosage. Staff carefully checked the medication and identified the discrepancy before administration. No medication error occurred.

    A communication error between staff created a risk of the student receiving a double dose or missing a dose. Staff awareness and a medication check identified the error before administration. No incorrect dose was given, and the student was not harmed.

     

    Remember:

    If there is a medication documentation error you must fill out an Incident Report rather that a Near-Miss report. 

    If a facility-related issue contributed to or played a role in the near miss, also complete a Facility Maintenance Request Form. I.e. Leaks, unusual noises, lighting.

     

  • Here are the policies related to this form:

    Accident & Incident Reporting Policy        Student/Participant Abuse Policy     

    Restrictive Use Policy

     

  • Date of near miss:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of incident:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Start time of occurrence:*
  • End time of occurrence:*
  • Incident start time:*
  • Incident end time:*
  • Names of student/participant involved: *
    Rows
  • Names of staff members involved: *
    Rows
  • The issue took place:*
  • Type of incident:*
  • Time, if known:*
  • Date the issue occurred:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Start Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • End Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Members of public involved?*
  • Observation Length
  • What were the contributing risk factors?*
  • Has the Principal or Program Director been notified of this concern in accordance with the Student/Participant Accident & Incident Reporting, Abuse, and Restrictive Use policies?
  • Was a physical injury observed?
  • Were any staff members injured?
  • Emergency contacts notified?*
  • Which room did you use?*
  • How would you describe the severity of this incident?*
  • Parents/guardians notified?*

  • Describe the incident

  • Were emergency services required?*
  • Was a PRN (pro re nata - as needed) administered*

  • The student/participant's medication administration record (MAR) must be completed. 

  • Was First Aid administered?*
  • Consciousness*
  • Breathing:
  • Did you call for help
  • Was the casualty transported to another location for treatment such as a hospital or walk-in-clinic?*
  • Did you contact a parent/guardian/ emergency contact?*
  • Were you the First Aider*
  • Location of injuries (student/participant 1)
  • Location of injuries (student/participant 2)
  • Location of injuries (student/participant 3)
  • Location of injuries (staff 1)
  • Location of injuries (staff 2)
  • Location of injuries (staff 3)
  • Date of submission
     - -
    2 digit month, 2 digit day, 4 digit year
  • Time of submission
  • Parent/Guardian Correspondence:
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