Incident Reports / Form
Hazard and Near Miss Report
A simple report for hazards and near misses observed during home care service delivery.
Example content
Preview the structure before opening the file
English structure excerpt · blank prompts, not a completed record
- Hazard details
- Date · Location
- Description
- What was observed · Potential risk
- Follow-up
- Coordinator notified · Action required
Read all template prompts
Hazard details:
- Date:
- Location:
- Hazard or near miss type:
- Observed by:
- Client informed:
Description:
- What was observed:
- Potential risk:
- Immediate action taken:
- Photos or evidence stored:
Follow-up:
- Coordinator notified:
- Action required:
- Owner:
- Due date:
- Review completed:
Who it is for
Workers and coordinators who need to record hazards before they become incidents.
When to use it
Use when a worker identifies an unsafe condition, near miss, access issue, environmental hazard, or equipment concern.
What this template helps with
A clearer record trail for everyday follow-up
Clear worker notes
Consistent records
Easier follow-up
Review notes
This template is a plain-language operational starting point. Check its fields, wording, and internal consistency before using it in a provider's own documentation system.