NEAR-MISS & INCIDENT REPORTING FORM

Near-Miss reports are intended as a means to quickly share information about incidents and near-misses within the project team. This form is to be completed immediately after an observation or event. Guidance: Provide available facts. Do not speculate. Do not complete blanks that are not applicable. Do not include names of persons or companies or identify third parties. Incident Date: Incident Time: City, State, Loc: PNL Office: Person Preparing Report: Signature: Office Manager: Responder Email:

Type of incident or significant near-miss/loss (check all that apply):

Injury (including first aid or RSI) Fire Spill/Release (any volume) Regulatory Action Property Damage Other (specify): Security Incident (theft, violence, kidnap, etc) Significant Near-Miss/Loss Describe POTENTIAL incident (e.g. serious injury, fatality, major spill, etc.)

Brief description of the following:

Event: (Draw a sketch. It will help clarify.) Injuries, if they have occured:

Responses which have taken place (e.g., first aid, medical visit, spill response, etc.):

Sketch of Office Location:

Corrective actions taken:

Version 2, 04SEP12

Form created by Project Navigator, Ltd.