INCIDENT ACCIDENT AND NEAR MISS REPORT FORM Apply Below ; Incident Accident and Near Miss Report Form Incident Accident Report Form Notify your manager AND complete this form ASAP after the incident or near miss.Name of Injured/ill person or name of persons involved in near miss. First Last Name of Witness First Last Details of EventWhat was the injury, accident or near miss?Tick treatment level: First Aid Doctor Ambulance Hospital Name of First Aider: First Last What treatment was given (if known):Who else was notified? First Last Injury Type or Equipment Involved in Near Miss (select as many as apply) Amputation Asphyxiation Bruise Burn Choking Concussion Cut Deafness Dermatitis Dislocation Foreign Body Fracture Illness Inflammation Strain/Sprain Wound Forklift Powertool Other - Please Specify Other, please specifyBody Part (select as many as apply) Ankle Chest Ear Elbow Eye Face Finger Foot Forehead Hand Head Hip Knee Lower Arm Lower Leg Mouth Neck Nose Shoulder Stomach Thigh Upper Arm Wrist Location (select as many as apply) Back Front Left Lower Right Side Upper Details of IncidentDate of Incident Date Format: DD slash MM slash YYYY Time of Incident : HH MM AM PM Date Reported Date Format: MM slash DD slash YYYY Location of incident:You may attach a drawing/map of area and photos as wellLocation of Incident - Image/s Drop files here or Provide exact details of what the person was doing when the injury / accident / near miss occurred:Attached photos below if possibleIncident Details - Image/s Drop files here or FRM-820 | Controlled Document Unless Printed | 2021 v1 | Reviewed 07/06/2021
