Accident/Near Miss Report
Name of Person Filling Out This Record?
First Name
Last Name
Email for Report
example@example.com
Company Name
URL Pre-fill
Nature Of Incident
Accident
Near Miss
Who Has Had The Accident?
First Name
Last Name
Who Has Had The Near Miss?
First Name
Last Name
Address of Person Involved In The Incident?
Street Address
Street Address Line 2
City/Town
County
Postal Code
Phone Number of Person Involved In Incident?
-
Area Code
Phone Number
Date of Incident
-
Day
-
Month
Year
Date
Time of Incident
Hour Minutes
AM
PM
AM/PM Option
Where Did the Incident Happen?
How Did The Incident Happen?
Has The Person Suffered an Injury?
Yes
No
What Is The Scale Of The Injury?
Very Minor Injury
Minor Injury
Medium Injury
Major Injury
Severe Injury
How Was the Injury Treated?
First Aid Administered
Referred to Hospital
What type of First Aid treatment was administered?
Who administered first aid?
First Name
Last Name
Did the person go to hospital?
Yes
No
What Was The Injury?
Notes
Photo If Required
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Name of Person Filling Out This Record?
First Name
Last Name
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