Near Miss Safety Incident

School:
Details of person reporting the incident
Person Type:
First Name: Surname:
Phone/Mobile:
Email:
Details of person involved in the incident
Person Type:
First Name: Surname:
Phone/Mobile:
Email:
When did the incident occur?

Did this incident occur over a period of time?

Please provide details
as to when this incident
first occurred:
Date: Time: :

Is this the first time the incident has been reported?

To whom and when was the incident reported?

First Name: Surname:
Date: Time: :
Location of incident

Did the incident occur on school grounds?

Please provide as much
detail as you can to
describe where the
incident occurred:
Details of incident
Please describe what
happened:
Additional information
Witness details:
Please include
name/s and
contact details
Related files:

File 1:

File 2:

File 3:

Message: