Audit

NAME OF PERSON WHO HAD THE NEAR MISS

NAME OF PERSON REPORTING THE NEAR MISS (if you did not have the near miss)

NEAR MISS DETAILS

Location

DESCRIBE WHAT HAPPENED (include pictures in the box below if possible)

Picture of near miss

WHAT WAS THE POTENTIAL INJURY.

COULD THIS HAVE BEEN AVOIDED.

Could any of the following have helped to a avoid this near miss?

PPE

Training

Toolbox talk

Name

NOW SEND THIS FORM TO YOUR MANAGER.

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.