Near Miss Form

• Document No.

• Personnel

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Details of Individual

• Name

• Department

• Location of Near Miss

• Select date

  Date

Witness Details

• Witness Name 1

• Witness Name 2

Details of Near Miss

• Describe the near miss fully (including any damage to company property - if any)

• What factors were involved? (ie. lack of policy, lack of training, unsafe act, broken equipment etc)

Corrective Action

• Describe Corrective Action(s) taken (if any)

• Report submitted by

• Job Title

• Add signature

  Sign