Incident and Near Miss Reporting

Date and time of incident

年

月

日

時間

時間分

Location (site/room/online setting)

Name(s) of people involved

Email

Provide a clear, factual description of the incident or near miss

Details of actions taken (e.g. who provided first aid or time emergency services were called)

Approximate number of individuals affected

What do you think caused the incident or near miss?

What steps have been or will be taken to prevent recurrence?

If witnesses, please enter contact details

Witness statement taken?

Signature

手書きモードが選択されています。手書きにはマウスまたはタッチパッドが必要です。キーボードのみで操作する場合は、「キーボード」または「アップロード」を選択してください。