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Printable near Miss Report Template  Form

Printable near Miss Report Template Form

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University. Department: Building: Time of Incident: ☐am ☐pm Room #: Date of Incident: Designation: ☐Faculty ☐Staff ☐Student ☐Other: Check all appropriate conditions: ☐ Near miss ☐ Safety concern ☐ Safety suggestion ☐ Other: Type of concern: ☐ Unsafe act ☐ Unsafe condition ☐ Unsafe equipment ☐ Unsafe use of equipment ☐ Other: Thoroughly describe the potential incident /hazard/concern (possible effects, etc) : (Optional) Name: Date Reported: Contact Information: Submit this form to...
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Instructions and help about near miss report example pdf

In this video we're going to describe briefly how to complete the near-miss reporting form I'm going to open a form using the desktop icon and if you don't have a desktop icon there is a training video on how to put that on your computer and there's also a training video on the three different ways you can open a form if you want to complete one so once you've opened a form we want to rEvally highlight that the near-miss form should only rEvally be used when no significant harm came to the patient as a result of the event if there was rEvally actual inner injury involved you need to be reporting that through your incident reporting process in the practice other channels not through the near-miss form the very first question generally just asks you to describe what happened where did it happen who was involved kind of how what took place now in this response another warning caveat is to be very careful not to use any names or specific dates like date of birth etc we don't want anything

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