Near Miss and Accident Reporting Form

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Thanks for taking the time to report an accident or near miss. It's important we have a log of these so we can continue to improve the safety of the space.

What is your hackspace username or email address?

You are welcome to report an incident on behalf of another member or guest - please mention details of this in the fields below.

In some cases we may need to contact you for further information.

When did the accident (or near miss) happen?
*

YYYY

Time

Where in the space did the accident (or near miss) occur?
*

This gives us an overview of areas in the space which are more hazardous than others. You can include details of the tool in a later section.

General (Kitchen, Toilets, Comfy Area, Studio, Blue Room)

Craft Room

Print Room

Workshop

Metal working

Electronics and 3D Printing

Other:

Please tell us more about what happened and who was involved?
*

This should include (where relevant), the people around, any tools you were using, how and where you were (or could) have been injured, etc.

Is there anything the space could have done to prevent this from happening?
*

We will use this information to inform us of which tools require inductions, what those inductions contain, and anything around the space we can improve to make it safer.

Was any treatment necessary? Please select those that apply.

We use this information to gauge the severity of the report and to perform restocking of first aid kits.

Hospital

First Aid Kit

No treatment required

Other:

Required

Additional Information (Optional)

You can mention anything you feel might be relevant to the incident which doesn't fit in to a field above, or to provide feedback on the reporting process.

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