Title Page

  • NMIH Number: (HV-SCT Office use only)

  • Date / Time

  • Location:
  • Business Unit

  • I wish to report a:

  • Describe the Near Miss / Incident / Hazard

  • Upload a photo

  • How serious could the outcome have been?

  • What action has been taken to address the issue?

Have you told your ARTC Manager about this?

  • Yes

  • No

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.