Near Miss / Incident reporting form

Basic Details

Group *

Location of near miss *

Apartment, suite, etc

City

ZIP / Postal Code

Country

Date of near miss *

Time of near miss *

Hours

Minutes

AM/PM

Activity taking place *

Your Details

Name of person completing form *

Role *

Membership Number *

Email Address *

Phone *

Were you directly involved? Or a Witness? *Directly involvedWitness

People Involved

Were any young people invovled? *YesNo

Were adults involved? *YesNo

Approx. number of people involved *

Names of individuals involved *

Ages of those involved *

Details of incident

What happened? *

What could have happened if situations were different? *

How was the situation noticed or identified? *

Potential Risk

Who was at risk? *

How serious could the outcomes have been? *Minor injurySerious injuryFatal riskSafeguarding concern

Immediate actions taken

What immediate action was taken to make the situation safe? *

Was the activity stopped? *YesNo

Was first aid required? *YesNo

Was the responsible leader informed at the time? *YesNo

Learning

What changes could prevent this happening again? *

Does the risk assessment need updating? *YesNo

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