Incident Report Form Template: Near Miss Report Form

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Incident Report Form Templates

Near Miss Report Form
Site
Time
Department
Date of incident
Exact location
Name of person logging this incident
Position
Who was this incident reported to
Who was this incident reported by

Please describe this incident in detail
What task (if any) was the injured person performing at the time of the incident
What factors were involved in or led to the incident
Action taken to prevent further injury or reoccurrence
What further action is required to prevent reoccurrence