NEAR MISS & INCIDENT/ACCIDENT REPORT FORM Guide Name:(Required) Date of Event(Required) DD slash MM slash YYYY Time of Event: Location of Event:(Required) Name of Person Involved: First Last PhoneEmail Type of Incident:(Required)Near MissIncidentAccidentProperty DamageProperty LossNature of Incident:(Required) Description of the Event:(Required)Significant Natural Hazard Involved(Required) Yes No Incident Level Severity(Required)1 - Minor Impact2 - Minor Impact3 - Minor Impact4 - Medium Impact5 - Medium Impact6 - Major Impact7 - Major Impact8 - Life Changing9 - Life Changing10 - Life ChangingPlease refer to theFollowing chart for the Incident Level Severity// THIS IS A NOTIFIABLE EVENT - PLEASE NOTIFY WORKSAFE IMMEDIATELY // Other Useful InformationMindset at the moment of the event: Weather, snow and mountain conditions at the moment of the event: Personal thoughts on what could have been done different:Potential learning from the event: Δ
