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Accident/Near Miss Report Form
Accident/Near Miss Form
Text
Date
Fatal?
Agency of accident / serious harm
Body part
Date of accident / serious harm
Date of birth
Employer follow up / notes
Hours worked since arrival at work (employees only)
Location of place of work
Mechanism of accident / serious harm:
Name
Name of injured person
Nature of injury or disease
(specify all)
Occupation or job title of injured person
Period of employment of injured person
Position
Residential address of injured person
Sex
Shift
The injured person is:
The person reporting is:
Time of accident / serious harm
Treatment of injury
Where and how did the accident / serious harm happen?
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