Information

  • Document No.

  • Incident Location

  • Conducted on

  • Prepared by (witness of near miss)

  • Signature

1. WHAT HAPPENED ?

  • Detailed description of incident (consider the activity, what happened and why)

  • Provide more details if necessary:

  • Add/take picture of incident for record

2. INCIDENT INFORMATION

  • ACTIVITY - What was the activity at the time of the incident ?

3. HAZARD INFORMATION

  • Contributing Hazard Category (please select)

  • Who identified the hazard?

  • The potential for serious injury was:

  • Please take a photo if necessary:

FURTHER ACTIONS

  • 1. Update team of Near Miss and suggested actions 2. Update any corresponding SOP's/ risk assessments, inductions, etc. 3. Record in safety register.

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