Accident and near miss reporting
1. Reporting form
Accident/near miss report form
Turning Point Leeds
Section 1: General information
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Report date:
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Report time:
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Reporter’s name:
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Contact information:
Section 2: Incident details
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Date of incident:
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Time of incident:
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Location:
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Type of incident:
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Accident
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Near Miss
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Description of incident:
Section 3: Persons involved
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Name:
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Age:
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Position (e.g., Pupil, staff, visitor):
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Contact information:
Section 4: Nature of injury (if applicable)
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Type of injury:
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Cut
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Bruise
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Sprain
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Fracture
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Burn
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Other (Specify): __________
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Part of body affected:
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First aid provided:
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Yes
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No
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If Yes, describe:
Section 5: Witness information
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Witness name:
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Witness contact information:
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Witness statement:
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Section 6: Actions taken
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Immediate actions taken:
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Follow-up actions required:
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Person responsible for follow-up:
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Deadline for follow-up:
Section 7: Investigation
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Investigation conducted by:
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Investigation date:
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Findings:
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Root cause:
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Recommendations:
Section 8: Signatures
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Reporter’s signature:
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Date:
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Supervisor’s signature:
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Date: