This near miss template allows providing the description and photos surrounding the incident as well as inclusion of the names of other witnesses of the near miss.
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Information
Near Miss Report No.
Conducted on
Employee Name:
Employee Job Title:
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:
Location of Near Miss:
Describe the near miss:
Photo/s (optional):
Names of other witnesses:
Reporting person's Name and Signature:
Michael Gleese
Modebest Near Miss / Unsafe Observation Report
This near miss template allows providing the description and photos surrounding the incident as well as inclusion of the names of other witnesses of the near miss.
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.