Incident & Near-Miss Report Generator

This form documents an incident or near miss and the investigation of its causes. It is an internal record your company completes and keeps. Its purpose is to capture the facts, find the underlying causes, and record the actions that prevent a recurrence.

Report identification

Event details

Date of eventTime of eventLocation / work areaReported by (job title)Reported to (supervisor title)Date reported

People involved

Person(s) involved

Witnesses

What happened

Describe what happenedConditions at the time (lighting, weather, housekeeping, equipment/tools)PPE in use

Sequence of events (step by step)

Root cause analysis

Method usedRoot cause statement

Corrective actions

TemplaKit provides this blank form and guidance only. It does not investigate incidents, determine cause or recordability, or keep your completed report. Names, signatures, and dates are added by hand.