Information
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Near Miss Report No.
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Conducted on
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Employee Name:
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Employee Job Title:
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Instructions:
1. Required to be completed when you experience a Safety Near Miss in the workplace
2. To be completed in full and emailed to the Contract manager & the Health & Safety Dept. -
Near Miss Defined
OSHA and the National Safety Council defines a near miss as an “unplanned event that did not result in injury, illness or damage – but had the potential to do so.” -
Date & Time of Near Miss:
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Location of Near Miss:
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Describe the near miss:
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Photo/s (optional):
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Names of other witnesses:
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Reporting person's Name and Signature:
