Near Miss Incident Information Report Fillable

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User Manual: Near-Miss-Incident-Information-Report-Fillable

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Near Miss Incident Information Report
(A near miss does not result in injury, illness, or damage by definition, but it had the potential to do so.)
Near miss incident date:________________ Time:_________________
Reporting date:_______________________ Time:_________________
Council/BSA location:_______________________________________________________________________________________
Reporting person:___________________________________________ ❏ Leader

❏ Parent

❏ Other:____________________

Contact information:_________________________________________________________________________________________
Location of near miss:_______________________________________________________________________________________
Specific area where near miss occurred:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Cause of near miss:_________________________________________________________________________________________
________________________________________________________________________________________________________
Activity at time of near miss:__________________________________________________________________________________
Program/event/adventure code:________________________________________________________________________________
Description of the near miss (detailed):
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Did the near miss occur while transporting to/from an activity? ❑ Yes
Potential severity:

❑ Catastrophic–I

❑ Critical–II

❑ No

❑ Marginal–III

❑ Negligible–IV

❑ Unknown (See the back of this
sheet for definitions.)

Lessons learned (what could be done to prevent future occurrences):
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Witnesses (See the back of this sheet to enter.)
Return this completed form to your council’s designated user for entry into RiskConsole via MyBSA Incident Entry.

Near Miss Incident Information Report
(A near miss does not result in injury, illness, or damage by definition, but it had the potential to do so.)

Probability/Severity Definitions
Catastrophic–I
Examples: Fatal or lifetime impairment, loss of sight or limb or permanent facility loss or events with multiple
critical incidents or > $1 million in financial impact.
Critical–II
Examples: Temporary impairment requiring rehabilitation and/or lifetime partial impairment, loss of use of
but not loss of a limb or facility not a total loss but must be rebuilt or events with multiple marginal incidents
or < $1 million and > $100,000 in financial impact.
Marginal–III
Examples: Injury requires a physician to treat a temporary impairment with complete rehabilitation possible or
sutures, clean fractures, injuries requiring transport to off-site medical facilities or events with multiple negligible
incidents or < $100,000 and > $1,000 in financial impact.
Negligible–IV
Examples: First-aid injuries not requiring medical professional intervention or < $1,000 in financial impact.
Witnesses
Name:___________________________________________________________________________________________________
First
Middle
Last
Address:_________________________________________________________________________________________________
City
State
Zip
Home phone:______________________ Cell phone:_______________________ Work phone:______________________________
E-mail:___________________________________________________________________________________________________

Others
Adult leader’s name:________________________________________________________________________________________
First
Middle
Last
Address:_________________________________________________________________________________________________
City
State
Zip
Home phone:______________________ Cell phone:_______________________ Work phone:______________________________
E-mail:___________________________________________________________________________________________________
Information gathered at scene by:______________________________________________________________________________
Contact information:_________________________________________________________________________________________
Return this completed form to your council’s designated user for entry into RiskConsole via MyBSA Incident Entry.
680-017
2010 Printing
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