F088 Near Miss Report

• Site conducted

  Select
• Site Name & CBRL Number
  Address

• Date & Time of Near Miss Report

  Date

• Near Miss Reported BY: (Name, Position & Employer)

• Near Miss Reported TO: (Name, Position & Employer)

Details of the Near Miss

• Were there any witnesses to the near miss?

• When did the near miss occur?

• Where did the near miss occur?

• What PPE was being worn?

• Say how the near miss happened, giving a cause if you can, providing photographs if necessary.

• Please provide photographs of the near miss incident

  Media

• What local action has, or will be, taken to prevent recurrence e.g., RA.MS review?

Details of the person(s) who had the near miss (if applicable)

• Name

• Age / Date Of Birth

• Home Address

• Employer

• Employer Address

• Occupation