Heavy Civil Good Catch / Near Miss

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Contractor/ Personnel involved

SECTION I

• Date and time of incident

  Date

• Nature of the incident (i.e. fall, struck by, caught between, slip/trip)

• What Happened

• Add media

  Media

• How / Why did this happen:

• What is being done to prevent recurrence? Or if positive, encourage good actions

• Was there any witness(es)? If yes, provide name(s).

  Yes

  No

  N/A

• Add signature

  Sign