Complete this form as a means to report near-miss situations



Please tick all appropriate boxes

Unsafe Act

Unsafe Equipment

Unsafe Condition

Unsafe Use of Equipment

Risk of Environmental Damage

Description of incident or potential hazard

Any immediate action taken to mitigate / correct potential repeat occurance

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Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.