Title Page
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Site conducted
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Reported on
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Reported by
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Reported to
Description
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Near Miss is defined as: ‘’Any incident not involving injury but had the potential to do so”
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AREA: Give details of exact location
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Growing Room
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Workshop
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Office
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Yard
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Clean Room
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Warehouse
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Others:
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Description of incident: tick one of the boxes below that best describes the Near Miss
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Machinery
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Slip Trip Fall
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Fire and Explosion
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Transport on site
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Struck / Hit by
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Fall from height
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Handling/ Lifting
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Electrical
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Environmental / Chemicals
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Other:
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Brief description of a hazard
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Any witnesses? If ‘yes’ give name:
Follow up Investigation
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Investigation carried by:
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Date and time of investigation:
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Details of investigation
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Actions Sign off:
