Near Miss Report
Incident Report
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Near Miss Report
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Near Miss Report
Near Miss Report
Date
MM slash DD slash YYYY
Time of event:
Hours
:
Minutes
Reported By
Description of Incident/Near Miss
Detail any injuries sustained:
Was First Aid given?
Yes
No
Name of First Aider:
Treatment given & equipment used (plasters, gloves, etc.):
Was the person taken to hospital?
Yes
No
Was the person kept in hospital?
Yes
No
If YES, for how long?
Has any damage to plant, property, environment or loss of production been caused?
Yes
No
If YES, give details:
Detail causes of and/or events leading up to the Incident:
If necessary has accident book been completed?
Yes
No
Pictures of Incident
Max. file size: 2 MB.
Diagram/Sketches
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