Information

Near miss

Was there a near miss?

Site:

Witness:

Explain the near miss:

Date and Time:
Insert a photo: (Optional)
Incident Report

Was there an incident?

Site:

Witness:

Explain the incident

Date and Time:
Insert a photo: (Optional)
Opportunity for Improvement

Is there an opportunity for improvement?

Site:

Explain the opportunity for improvement?

Date and Time:
Insert a photo: (Optional)
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.