C2SC Near Miss Report

• Company Name

• Job Name

• Job Location
  Address

• Conducted on

  Date

• Prepared by

• A Near Miss is defined as an unplanned event that did not result in injury, illness, or damage - but had the potential to do so. Reporting a Near Miss will help our team identify the root cause of the incident so we can try and prevent a reoccurrence.

General Information

• Date & Time of Incident

  Date

• Time Work Started

• Specific Incident Location

• List person(s) involved

Incident Details

• Describe the Near Miss occurrence. If working and/or environmental conditions played a role in the incident, please add a description below. Include photos by selecting "Add Media" (if applicable).

• Near Miss description

• Working/environmental conditions (if applicable)

• Action Taken?

• Lessons learned?

• Add media

  Media