Near Miss Reporting Form - Dringhouses Scouts

Please use this form to report all near misses. Near misses are reviewed every term by the Group Exec so that we can improve safety. If you think that attention needs to be given to the hazard/ cause of the near miss more urgently please let Mike Hewitt know.

DATA PROTECTION: This form is used to collect information about you for the purpose of logging a near miss with Dringhouses Scout Group. This is to be used by Dringhouses Scouts. We do not share your personal data provided in this form with any third parties. The data provided in this form is stored securely at Dringhouses Scouts. We take your personal data privacy seriously. We will keep the data we capture from this form, in line with the Scout’s Data Retention Policy and it will be securely disposed of within a year of the incident being logged or once the incident case is closed, whichever is longer.

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

Phone