INCIDENT NEAR MISS REPORT
PROJECT NAME
INCIDENT/NEAR MISS REPORT NO
INCIDENT TYPE
Injury
Illness
Fire
Explosion
Property Damage
Near Miss
Vehicle Accident
Others
Date
-
Month
-
Day
Year
Date
Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
INCIDENT SEVERITY
Minor
Serious
Fatal
JOB SUPERVISOR
INCIDENT DESCRIPTION
Include details such as- Overview of the event,Activities performed,Equipment used,Working conditions,Competence for people involved, Any conditions which influenced the event
DETAILS OF INJURED PERSON (IF APPLICABLE)
Input N/A if Not applicable
IMMEDIATE ACTION TAKEN
CORRECTIVE ACTION TAKEN/TO BE TAKEN
SIGNATURE OF SAFETY ADVISOR
Submit
Should be Empty: