Form & Flow

Incident / Near‑Miss Report & Triage (Fillable)

A practical, fillable incident and near‑miss report with guided triage rules, suggested investigation depth, timelines, and communication templates. Designed to preserve evidence, prioritize investigation effort, assign ownership, and enable timely verification and learning.

Interactive Tool

Incident / Near-Miss Report & Triage

This form captures who/what/when/how, immediate containment actions, risk indicators, and suggested owners. Use the triage guidance below to assign investigation priority and depth so that resources match risk. If you are unsure at any point, select 'High' and notify your supervisor immediately.

Triage guidance (use these rules to choose Suggested Priority)

Use the two scales below: Potential Severity (1–5) and Likelihood of Recurrence (1–5).
Multiply severity × likelihood to get a Triage Score.
Map the score: 1–3 = Low (document & monitor), 4–7 = Medium (simple RCA / corrective actions), 8–11 = High (structured RCA, timely actions), 12–25 = Critical (immediate stop, full A3, senior leadership)

This form saves your submission and notifies the suggested owner when provided. For attachments (photos, logs), paste a secure link in the Photos / Evidence field.

Report ID

Leave blank to auto-generate or enter an existing tracking number.

Your name

Name of the person submitting this report.

Contact (email / phone)

So we can follow up with questions. Optional if anonymous reporting is used.

Role / job title

Department / team

Location (site / area / line)

Date and time of event

Use local date/time. If unsure, estimate and mark in description.

Type of event

Choose the closest match.

Brief summary (one or two sentences)

What happened in plain language?

Detailed description (what happened, sequence of events)

Include steps, timings, people, and conditions that led to the event.

Immediate containment / actions taken

What was done right away to stop harm, preserve evidence, or protect people?

Potential severity (1 = minor, 5 = severe)

Rate the worst credible harm if not controlled.

1.0 10.0

Likelihood of recurrence (1 = unlikely, 5 = very likely)

How likely is a similar event to happen again under current conditions?

1.0 10.0

Triage score (severity × likelihood)

Optional: calculate or enter the product of the two scales. If left blank, reviewer will calculate.

Suggested priority

Use triage rules in the intro to select priority.

Suggested investigation depth

Pick the recommended investigation method.

Documented review (record findings, verify containment)

Simple RCA (5 Whys / quick root cause)

Full A3 / structured RCA (multi-discipline)

Witnesses / people involved (names & contacts)

Equipment, material, or process involved

Photos / evidence links

Paste secure links to photos, logs, or attachments. File upload may be available in your site-specific implementation.

Suggested owner for investigation

Person or role who should lead the follow-up (name or role).

Is immediate containment complete?

Is stop-work required now?

If yes, notify management and secure the area immediately.

Required follow-ups / recommended corrective actions

Target due date for verification / actions (YYYY-MM-DD)

Who should be notified (stakeholders / distribution)

Confidential / anonymous report requested?

Reporter name (signature)

Typing your name confirms the accuracy of this submission.

Verification complete (to be filled by owner)

Verification date (owner)

Owner comments and actions taken (owner)

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Incident / Near‑Miss Report & Triage (Fillable)