Incident report No......./....../.......
Incident/Near miss investigation form
The reason for investigating an incident or near miss is to determine: the cause or causes of the incident; to
identify any risks, hazards, systems or procedures that contributed to the incident; and to recommend
corrective action to prevent similar incidents.
Incidents should be investigated by people knowledgeable about the type of work involved at the time of the
incident. Relevant workers should also be involved in the investigation.
An incident /near miss investigation report should answer the WHO, WHERE, WHEN, WHAT, WHY and
HOW questions with regard to an incident.
Details of the incident/near miss:
Date of incident:
Time of incident:
Short description of incident / near miss:
Area where incident / near miss occurred:
Details of the incident/near miss investigation
Name of injured person (if relevant):
Injury sustained(if relevant):
Name of person who reported incident:
Date of report: