Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

Untitled Page

  • Are you reporting a hazard or near miss?

  • Description of hazard or near miss?

  • My suggestion for removing hazard or preventing a re-occurence of near miss?

  • Name

  • Position

  • Signed

  • Date

  • Feedback and record of actions (to be completed by Manager/Supervisor

  • Confirmation the hazard/action has been resolved

  • Managers name

  • Managers signature

  • Date

  • Originators name

  • Originators signature

  • Date

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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.