Hazard and Near Miss Report Form - Traffic Management

• Conducted on

  Date

• Prepared by

• Location
  Address

• Company (If Sub-contractor):

• Task/job being carried out

• What is being reported?

  Select

• Description of Hazard

• Description of Near Miss

• Description of immediate actions taken:

• Has the hazard or near miss been reported?

• Please state date and time of incident

  Date

• Please now close form and save it as in progress in order for the Health and Safety Manger to fill in their report.

Health and Safety Managers Report

• Actions taken

• Date of report completion

  Date

• Signature of Health and Safety Manager

  Sign