FGPC & SWF Near Miss Incident Report Form
A near miss does not result in injury, illness, or damage by definition, but it had the potential to do so. It is everyone's responsibility to report and/or correct these potential accidents/incidents immediately. For a description of potential severity definitions, go to http://goo.gl/iU6r2x
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Date & Time of Near Miss *
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YYYY
Time
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Today's Date & Time *
MM
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DD
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YYYY
Time
:
Reporting Person *
Name of person reporting the near miss
Email of Reporting Person *
Name of person reporting the near miss
Contact Information *
Phone number and email of person reporting near miss
Location of near miss *
Specific area where near miss occured
Please check all appropriate conditions
Cause of near miss *
What were the primary and contributing hazards to cause the near miss
Activity at the time of near miss *
What activity (if any) was taking place prior and at time of the incident
Name of program or event *
Description of near miss *
Did the near miss occur while transporting to/from an activity? *
Potential Severity
Clear selection
Lessons Learned *
What corrective action could be done to prevent future occurrences?
Witnesses *
Name and contact information for at least 2 witnesses
Notes
Any additional information you find relevant
Submit
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