Accident Analysis

Reporting Near Miss Form — Sample

Department _________________________________________

Date _______________________________________________

Name of the employee or volunteer ______________________

Name of the departmental supervisor ____________________

Nature of incident ____________________________________

Why was this incident considered a "near miss"? ____________

____________________________________________________

Was the employee, volunteer or contractor counseled/reprimanded?

____________________________________________________

Why or why not? _____________________________________

Remedial activities or training recommended _______________

____________________________________________________