Tim Bentley

NEAR MISS / HAZARD REPORT FORM

Use this form to report events that had the potential to cause injuries, Ill health or damage and email it to your manager, and the Group SHEQ Manager: tim.bentley@walkers-transport.co.uk

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Title Page

Date / Time
Site / Depot
Location:

Near-miss / Hazard report

Please select near miss type:
- Near Miss
- Unsafe Condition
- Unsafe Act
Describe what you have seen: (take a photograph if possible)
Describe what could have happened:
Describe what you were able to do about it or suggest actions required:
Was there anyone involved in the Near-miss / Hazard?
What is the Job description of the person involved in the Near-miss?
Was the correct PPE being worn?
Lighting conditions:
Your name
Your Position:
Contact number or email (Optional).
If you have any Health and Safety queries and to report this near miss by email contact tim.bentley@walkers-transport.co.uk

Tim Bentley

NEAR MISS / HAZARD REPORT FORM

Use this form to report events that had the potential to cause injuries, Ill health or damage and email it to your manager, and the Group SHEQ Manager: tim.bentley@walkers-transport.co.uk

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.