Accident, Incident, Near-Miss Report Form

Accident, Incident, Near-Miss Report Form

Complete this form for each incident, accident or near miss within 24 hours of the date in which the incident or accident was reported. Incident Reporting ensures there is a record of the incident on file and helps provide for a safer work environment.

This form must be completed in the event of an actual/potential; accident, injury, fire, explosion, impact, puncture, electrical shock, fall, entrapment, spill/exposure to chemical, biological, or radiological material etc.. Regardless of whether an injury or illness occurred. It may be completed by the person affected by the incident, a witness, supervisor or instructor. If you are an employee or bursary student who was injured on the job, the Human Resources Department will contact you directly regarding your workplace injury and assist you with the workers’ compensation claims process. Filing of this Accident Investigation/Root Cause Analysis is not filing a workman compensation claim. An employee retains his/her right to file a workers’ compensation claim at a later date. University employees may need to complete additional forms as required by human resources.

1Incident Summary > 2Contributing Factors > 3Investigation > 4Review Your Entry
SECTION 1

Incident Summary
Affected Individuals Name
Employee/Student #
Email Address
Affected Individual’s Affiliation
Home Address Home Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Date of Birth Date of Birth / MM / DD YYYY
Best Contact Number Best Contact Number - ### - ### ####
Your Name Your Name First Last
Your Email Address
Your Affiliation
Supervisor/Department Contact Name Supervisor/Department Contact Name First Last
Supervisor/Department Contact Email
Lab Manager
Other Lab Manager Email
Accident/Incident/Near Miss Date Accident/Incident/Near Miss Date / MM / DD YYYY
Time Time : HH MM AM/PM
Is the Scene Safe?

Is the Scene Safe? Yes No
Exact location of the accident, incident or near miss
What task was being performed, how did it happen, and explain the nature of the injury?
Specifically, What body part was injured?
Did you/affected individual seek medical attention?

Did you/affected individual seek medical attention? Yes No
Location where medical attention was provided Location where medical attention was provided
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Were witnesses present?

Were witnesses present? Yes No
List Witnesses:
How much experience did the affected party have in performing this task?
Please list your most recent applicable training with date of completion.
Upload a Picture

Attach Files
Was the individual wearing PPE?

Was the individual wearing PPE? Yes No
Respirator Hearing Protection Dust Mask Foot Protection Eye Protection Lab Coat Hand Protection Face Shield Other Other
Was safety equipment used to control the hazard?

Was safety equipment used to control the hazard? Yes No
Biological Safety Cabinet Chemical Fume Hood Containment/Isolation Machine Guard Other Other
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