Title Page

  • Location of hazard

  • Conducted on

  • Prepared by

  • Name of person who reported the near miss (this can be yourself or on behalf of someone)

  • Precise Location (e.g. Prees Mill Yard, near Trailer 200)

  • Date and time of near miss

  • Please describe the near miss (photos can be added if needed)

  • Names of any witnesses

  • Signature:

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.