Near Miss Incident Report Mobile App

Included Fields

Customize to add, remove, or edit any of the fields below.

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  Severity Actual

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  Potential

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  Preventable

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  Non Preventable

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  Date of Incident

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  Date Reported

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  Time

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  Incident Location (site)

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  Department

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  Worker Involved

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  Last Name

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  First Name

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  Department

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  # Hours Worked Prior to Incident

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  Last Name

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  First Name

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  Department

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  # Hours Worked Prior to Incident

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  Supervisor

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  Last Name

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  First Name

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  Division

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  Incident Description (Include who, what, where, how, part, components)

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  Picture

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  Picture

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  Supplemental Reports Attached

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  Signature of Worker

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  Visibility

• ...and More!