Accident, Incident or Near Miss Reporting Form

Accident, Incident or Near Miss Reporting Form
This form is a vital tool for ensuring the safety and wellbeing of all individuals involved in COVEY’s activities. By accurately reporting accidents, incidents and near misses staff are contributing to the continuous improvement of our risk management practices.

It supports safeguarding policies, legal compliance, promotes accountability and helps prevent future occurrences through informed decision-making. The form should be completed as soon as reasonably practical after any accident, incident or near miss and forwarded on to their line manager for review.
Details of Incident
Date of Event:

DayMonthYear
Date
Time of Event:

Hour Minutes

AM/PM Option
Location of Event:
Type of Event:
- Accident - an unplanned event that results in injury, illness, or damage to property or the environment.
- Incident - any unplanned event that disrupts normal operations but does not result in injury. It may still cause damage to property or require investigation.
- Near Miss - an unplanned event that did not result in injury or damage, but could have, if circumstances were slightly different.
Using the guidance above, please specify the type of event:

AccidentIncidentNear Miss
Category of Event (select all that apply):

Slip, trip or fallEquipment failureIllnessViolence or abuseVehicleOther
If you selected other, please specify below:
Name of person involved:

First NameLast Name
This person is a:

ParticipantVolunteerStaff memberOther
If you selected other, please specify below:
Reported by:

First NameLast Name
Date of Report:

DayMonthYear
Date
Name of person responsible for the session (1-1, group or outing):

First NameLast Name
What Happened?
Please describe the event clearly and factually. Include what led up to the event and what occurred:
Please note: if the event relates to a Safeguarding concern, please update the log on Sharepoint and ensure relevant parties, such as Social Work, have been informed.
Was anyone injured or harmed?

YesNo
If yes, please describe the injury and any first aid administered/actions taken:
Were there any witnesses?

YesNo
If yes, please list all the witnesses:
Risk Assessment Evaluation
Was there a Risk Assessment in place prior to the event?

YesNo
If yes, was it assessed and followed?

YesPartiallyNo
In light of the event, does the individual, group and/or activity risk assessment need reviewed?

YesNo
If yes, please detail new control measures to be considered for any risk assessments in place. This can include provider’s own assessments or disposal of defective equipment if applicable:
Name of person responsible for updating the risk assessment:

First NameLast Name
Date for the review or completion of updated risk assessment:

DayMonthYear
Date
Does this incident require escalation to the CEO/Board?

YesNo
Name of person completing this form:

First NameLast Name
Line Manager sign off:

First NameLast Name
Senior Leadership Comments (if applicable):
Should be Empty:

Accident, Incident or Near Miss Reporting Form

Details of Incident

What Happened?

Risk Assessment Evaluation