Near Miss Incident Report

1) Report Type

2) Date Occurred (MM/DD/YYYY)

3) Time (HH:MM AM/PM)

4) County

5) Employee Type

6) Attachments

7) Location

8) Functional Section

9) Employee’s Name (Optional)

10) Describe fully how and where the incident occurred.

11) Likelihood of Exposure

12) Incident Severity

Questions? E-Mail Julianny.Acosta@dot.state.fl.us or dial (352) 955-6601.