Apurba Saha

HAZARD & NEAR MISS REPORT

CDX Exploration

Use this Template

Print as PDF

Use this Template

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Title Page

Site conducted
Date of Occurrence
Time of Occurrence
Details
Shift
Location/Site of Occurrence
Reported by
Position
Employee Type

Incident Details

Description of Incident
Media
Hazard Category
Potential Impact Type
Potential Severity
Severity Matrix Table:
Immediate action taken and initial investigation findings
Has the risk been controlled?
Are further actions required?
Name of person assigned further actions
Details of further action required
Date actions to be completed by
Signature

Apurba Saha

HAZARD & NEAR MISS REPORT

CDX Exploration

Use this Template

Print as PDF

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.