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
DESCRIBE WHAT HAPPENED (include pictures in the box below if possible)
WHAT WAS THE POTENTIAL INJURY.
COULD THIS HAVE BEEN AVOIDED.
Could any of the following have helped to a avoid this near miss?
NOW SEND THIS FORM TO YOUR MANAGER.