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MIA ROSE ELECTRICAL SOLUTIONS - INCIDENT / NEAR MISS REPORT
Document incidents, injuries, property damage, and near misses with clean site records.
Report Date
Event Date
Event Time
Job Site
Reported By
Supervisor
Report Type
Near Miss
Incident - No Injury
Incident - First Aid
Incident - Medical Aid
Property Damage
Environmental
Other
Person(s) Involved
Incident Details
Exact Location
What Happened?
Task / Activity at Time of Event
Immediate Action Taken
Injury / Damage Information
Was There an Injury?
No
Yes
Medical Treatment Required?
No
First Aid Only
Medical Aid
Emergency Response
Property / Equipment Damage?
No
Yes
Estimated Loss / Damage ($)
Injury / Damage Details
Cause & Corrective Action
Contributing Factors / Possible Causes
Root Cause / Main Cause
Corrective Actions / Preventive Measures
Follow-Up Required
Witness Information
Witnesses
+ Add Witness
Reported By Sign-Off
Typed Signature
Draw Signature
Clear Signature
Supervisor Sign-Off
Typed Signature
Draw Signature
Clear Signature
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