Information
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Conducted on
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Employee Name
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Staff Number
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Shift
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Near Miss Defined
OSHA and the National Safety Council defines a near miss as an “unplanned event that did not result in injury, illness or damage – but had the potential to do so.” -
Date & Time of Near Miss:
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Location of Near Miss (please describe specific location).
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Select the category the near-miss most relates to:
- Fall from height
- Trip / Fall on same level
- Fall from equipment
- Hazardous Manual Handling
- Electric Shock
- Caught between/underneath
- Hazardous Substance
- Falling object
- Other
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Describe the Near Miss (please provide as much detail as possible).
