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Near Miss Form

If you are human, leave this field blank.

Name of Person Reporting Near Miss *

Email Address for your copy

Location of Near Miss *

Date of Near Miss *

Time of Near Miss *

Description of Near Miss *

Has first aid been administered ? If yes please give details. *

E01 - contact with moving machinery or material being machined

Yes

E02 - struck by moving, including flying or falling objects

Yes

E03 - struck by moving vehicle

Yes

E04 - struck against something fixed

Yes

E05 - injured while handling, lifting or carrying

Yes

E06 - slip, trip or fall on same level

Yes

E07 - fall from a height

Yes

E08 - trapped by something collapsing or overturning

Yes

E09 - drowning or asphyxiation

Yes

E10 - exposure or contact with harmful substance

Yes

E11 - exposure to fire

Yes

E12 - exposure to an explosion

Yes

E13 - contact with electricity or electrical discharge

Yes

E14 - injured by an animal

Yes

E15 - violence/aggression (physical or verbal)

Yes

E16 Other

Name of Injured Person *

Address of Injured Person if not School *

Injured Persons Date of Birth *

Employee Status of Injured Person

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Tel/Ffôn: 01495 765800
E-mail/E-bost: staenquiries@stalbans.schoolsedu.org.uk

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