Close Call Report Form

"*" indicates required fields

Name*

Email*

Phone*

Who/What area would be responsible for the closing out this close call?*

Event Date*

Event Time*

Location*

Please provide as much detail as possible. ELR, Mileage, Address

Incident Detail:*

Please provide a description of the issue with as much detail as possible. It is helpful if you can provide details of the activity taken place at the time of the event.

What Could have happened?*

A brief description of what could have happened due to this close call.

What were you able to do about it?*

Please state what was carried/completed to reduce/remove immediate risk? If the risk is still present, what action(s) is required to be carried out?

Has the issue been resolved?*

Yes

Name

This field is for validation purposes and should be left unchanged.

Close Call Report Form

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