Matthew Oneill

Near Miss form

Use this near miss form to quickly record the incident and indicate of work stopped or continued business as usual.

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Use this Template

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Information

Conducted on
Site
Employee Name (optional):

Information

Instructions:
1. Required to be completed when you experience a Near Miss in the workplace
2. To be completed in full and given to the Health & Safety Manager or Supervisor to pass on.
Near Miss Defined
A near miss as an “unplanned event that did not result in injury, illness or damage – but had the potential to do so.”
Location of Near Miss ?
Date & Time of Near Miss:
Photo/s that can help explain the near miss:
Please explain the near miss that occurred:
Stop work or work business as usual?
Name and Signature (optional)

Matthew Oneill

Near Miss form

Use this near miss form to quickly record the incident and indicate of work stopped or continued business as usual.

Use this Template

Print as PDF

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.