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Easter Entrance
Staff Near Miss

Report Form

Near Miss Report Form

Please use this form to report a near miss or safety concern.
What department do you work in?
Is it a near miss or a safety concern? * A near miss is an unplanned event that did not result in injury, ill health, damage, or loss, but had the realistic potential to do so. A safety concern is any hazard, unsafe condition, or unsafe behaviour that could cause harm if left unaddressed
Detail the specific location the near miss/safety concern occurred.
Date that the near miss occurred or safety concern was discovered
The time the near miss occurred or safety concern was found
(e.g. slip/trip, electrical, falling object, damaged flooring, obstructed escape routes)
Please describe the near miss/safety concern
Did you take any immediate actions to make the area safe or address the safety concern/near miss? If yes, please provide details.