Hazard and Near Miss Report
A simple report for hazards and near misses observed during home care service delivery.
Incident Reports / Form
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
Using this resource
Describe what you observed, where it happened and the immediate action taken without guessing a cause.
A near miss connected with care delivery may itself be an incident for the provider's incident management system even without actual harm. Record and review it there; assess any SIRS notification obligation separately using current Commission guidance.
Assign an owner to review the remaining risk. Completing this form neither makes the area safe nor determines reportability.
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
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.