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Free Near Miss Incident Report Form Template

Free Near Miss Incident Report Form

Name: Free Near Miss Incident Report Form Template
Brand: Template.net
Availability: InStock

Near Miss Incident Report Form

Please complete this Near Miss Incident Report Form Template to document and assess incidents that could have resulted in injury or damage but were narrowly avoided.

Date of Near Miss

Time of Near Miss

Description

Location

Name of Reporter

Position/Job Title

Phone number

Describe the Incident

Provide a brief description of what happened and how it occurred

What was the potential risk or injury that could have occurred?

Describe the potential consequences of the near miss

Were there any witnesses?

If yes, list names and contact information.

Witness Name	Phone Number

Immediate Actions Taken

What was done immediately after the near miss to prevent an incident?

Recommendations to Prevent Future Incidents

Any suggestions for corrective actions or improvements?

Reported By

Name:

Date:

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Prevent future accidents by documenting close calls with our Near Miss Incident Report Form Template on Template.net. Fully customizable and editable, this template allows you to accurately capture the details of near-miss incidents for safety reviews and improvements. With the AI Editor Tool, you can quickly modify the form to fit your organization's safety protocols, ensuring thorough and efficient reporting.