Baileys Hazard Spotting & Near Miss Reporting Form

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• 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

  Sign

• Date

  Date

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

• Confirmation the hazard/action has been resolved

  Yes

  No

  N/A

• Managers name

• Managers signature

  Sign

• Date

  Date

• Originators name

• Originators signature

  Yes

  No

  N/A

• Date

  Date

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