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Emergency Help
Incident and Near Miss Reporting
Date and time of incident
*
Day
Month
Year
Time
:
Hours
Minutes
Location (site/room/online setting)
*
Name(s) of people involved
*
Email
*
Type of Event
*
Accident
Injury
Illness
Near Miss
Property Damage
Other
Provide a clear, factual description of the incident or near miss
*
Immediate Actions Taken
*
First aid given
Emergency services called
Equipment isolated/area made safe
Supervisor/manager notified
Other
Details of actions taken (e.g. who provided first aid or time emergency services were called)
*
Approximate number of individuals affected
*
What do you think caused the incident or near miss?
*
What steps have been or will be taken to prevent recurrence?
*
If witnesses, please enter contact details
Witness statement taken?
Signature
*
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