Information
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Document No.
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Document title
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Client / Site
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Conducted on
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Personnel on site
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Depot
- Croydon
- Shenley
- Richmond
- Ealing
- Portsmouth
- Birmingham
- Hastings
- Bexley
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NAME OF PERSON WHO HAD THE NEAR MISS
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NAME OF PERSON REPORTING THE NEAR MISS (if you did not have the near miss)
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NEAR MISS DETAILS
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Location
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DESCRIBE WHAT HAPPENED (include pictures in the box below if possible)
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Picture of near miss
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WHAT WAS THE POTENTIAL INJURY.
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COULD THIS HAVE BEEN AVOIDED.
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Could any of the following have helped to a avoid this near miss?
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PPE
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Training
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Toolbox talk
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Name
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NOW SEND THIS FORM TO YOUR MANAGER.
