Good Catch / Near Miss Report

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Contractor involved.

SECTION I

• Date and time of incident

  Date

• Nature of the Incident (i.e. Fall, struck by, caught between, slip/trip)

  Select Fall Struck By Caught Between Slip/Trip Defective Equipment Improper/No PPE Electrical Hazard

  • Fall
  • Struck By
  • Caught Between
  • Slip/Trip
  • Defective Equipment
  • Improper/No PPE
  • Electrical Hazard

• What Happened

• Please provide photo

  Media

• How / Why did this happen:

• What is being done to prevent recurrence?

• Was there any witness(es)? If yes, provide name(s).

  Yes

  No

  N/A

• Add signature

  Sign