Quench Canada- Incident/Near Miss Report

Incident / Near Miss Report

Please fill out one form per unit.
Date Submitted

MonthDayYear
Event
An incident is an event that did cause injury to a person or damage to equipment, building, or materials. A near miss is an event that could have caused injury to a person or damage to equipment, building or materials.
Form Initiator
Employee
Manager
Witness(es)
Date of Event

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Event

Hour Minutes

AM/PM Option
Date Reported

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Location where event occurred
Start of shift on day of event

Hour Minutes

AM/PM Option
End of shift on day of event

Hour Minutes

AM/PM Option
Full description of event
List all equipment, machinery, materials or chemicals employee was using when event occurred
Identify factors that you believe contributed to or caused the event
Nature of injury (strain, cut, bruise, etc.)
Body parts affected
Medical treatment required:
Name of Hospital or Attending Physician
Was the employee hospitalized overnight as a patient?
Did employee leave work due to injury?
If Yes, at what time?

Hour Minutes

AM/PM Option
Date of return to regular duty

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Add photos to support each of the above

Cancelof
Complete this section if an injury occurred or there was damage to equipment
Were proper procedures being followed when incident occurred?
If No, explain:
Was employee wearing proper personal protective equipment?
If No, explain:
Are changes in equipment necessary to prevent a recurrence?
If Yes, explain:
Employee Signature
Manager Signature
Submitted by
Should be Empty:

Incident / Near Miss Report