Mini Near Miss Report

• Document No.

• Date and Time of occurrence

  Date

• Report completed by

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

• PLANON Number

• Location

• Address
  Address

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

• Photo of area

  Media