Clearvision Near-Miss Report

• Document No.

• Audit Title

• Client / Site / Project

• Investigation conducted on

  Date

• Prepared by

• Location
  Address

Near-Miss Details

• Date & Time of Near-Miss

  Date
• Location of Near-Miss
  Address

• Site / Project Name

• Near-Miss Details

  Select Unsafe behavior Unsafe Work Area Equipment Defects Unauthorized Equipment Use Improper Equipment Use Lack of protective safety devices Employee operating at inappropriate speed Equipment used outside rated capacity Lack of PPE Inappropriate PPE Untidy Conditions (Poor Housekeeping) Safety procedures not followed Inadequate ventilation Drugs or Alcohol Other

  • Unsafe behavior
  • Unsafe Work Area
  • Equipment Defects
  • Unauthorized Equipment Use
  • Improper Equipment Use
  • Lack of protective safety devices
  • Employee operating at inappropriate speed
  • Equipment used outside rated capacity
  • Lack of PPE
  • Inappropriate PPE
  • Untidy Conditions (Poor Housekeeping)
  • Safety procedures not followed
  • Inadequate ventilation
  • Drugs or Alcohol
  • Other

• Please describe type of Near-Miss

Evidence and Attachments

• Which of the following do you need to attach to this report to accurately document this Near-Miss?

  Select Evidence Equipment Details Vehicle Details Damages Other Items

  • Evidence
  • Equipment Details
  • Vehicle Details
  • Damages
  • Other Items

Evidence Log

• Please log all relevant evidence below

Evidence

• Photos of evidence or hazard

  Media

Person reporting

• Full Name

• Contact phone number

Corrective Actions

• Are corrective/further actions required with regard to this near-miss?

  Yes

  No

• Please detail corrective/further actions required.