Near Miss Reporting Form – 2nd Acomb Scout Group

Name *

In case we need to get in touch to obtain further information about the incident

Phone Number *

In case we need to get in touch to obtain further information about the incident

Email Address *

In case we need to get in touch to obtain further information about the incident

Date & Time of the Incident *

Date

Time

Location of the incident *

Circumstances surrounding the incident *

What was happening, activity, game, free time etc?

Description of the incident (near miss) *

In as much detail as possible please describe what happened, what went wrong and why. The more details you can provide the more useful it will be in trying to prevent similar instances in the future.

Follow-Up

Please inform me of the outcome of any investigation and resulting policy / rule change