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Accident/Near Miss Report Results
Accident/Near Miss Report
Text
Date
Name
Position
The person reporting is:
Location of place of work
Name of injured person
Residential address of injured person
Date of birth
Sex
Occupation or job title of injured person
The injured person is:
Period of employment of injured person
Treatment of injury
Time of accident / serious harm
Date of accident / serious harm
Shift
Hours worked since arrival at work (employees only)
Mechanism of accident / serious harm:
Agency of accident / serious harm
Body part
Nature of injury or disease
Fatal?
Where and how did the accident / serious harm happen?
Employer follow up / notes
1
Clearview Cleaning Accident Form
10/13/2023
The employee
10/20/2023
Environmental exposure (e.g. dust, gas)
Lower limb
2
Clearview Cleaning Accident Form
10/13/2023
The employee
Non-powered handtool, appliance, or equipment
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