Incident and Near Miss Reporting

Date and time of incident

Día

Mes

Año

Horario

HorasMinutos

Location (site/room/online setting)

Name(s) of people involved

Email

Provide a clear, factual description of the incident or near miss

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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