Near Miss Form

Use this form to report any near miss incidents which may occur

Your Details

First Name

Last Name

Phone

(###)

###

####

Your church serving role that day

Today's Date

YYYY

Tell us about the incident

What date did the incident take place

YYYY

What time did this take place?

Hour

Minute

Second

Where did this take place?

Description of the activity taking place when the incident or near miss occurred

For Example: kids free play time, kids structure time, event set-up

Detailed description of the accident or near miss

This needs to be as detailed as possible, considering: Who, What, Where, Why, When and How

Which of the following best describes the incident?

Who saw and reported the incident?

What action was taken and who else has been informed?

In the event of more serious accidents, complete a relevant accident form.

A safeguarding lead must be informed by at the earliest suitable opportunity if any person, whether a member of the Church or not: • Suffers personal injury or illness where that injury or illness necessitates medical treatment (treatment by a doctor, dentist, nurse, paramedic or at a hospital). Minor injuries or illness not requiring such treatment must be recorded locally, with UK Headquarters being informed if they subsequently receive medical attention • Requires rescuing where rescue involves any Emergency Service: Police, Fire, Ambulance, Mountain Rescue or Coastguard • Dies in the course of, or arising out of, a Church activity or while on, or in conjunction with, any Church property. If an accident during a Church activity results in third party damage, Church Leadership must be informed at the earliest suitable opportunity.