Near Miss / High Potential Reporting

• Audit Title

  Near Miss

  High Potential

• Document No.

• Site name

• Conducted on

  Date

• Client

• Prepared by

• Location
  Address

Near Miss / High Potential Report

• A near miss is a potential hazard or incident that has not resulted in any personal injury. Unsafe working conditions, unsafe employee habits, improper use of equipment or use of malfunctioning equipment have the potential to cause work related injuries. It is everyone's responsibility to report and/ or correct these potential accidents/incidents immediately. Please complete this form as a means to report these near-miss situations. “High Potential” incidents are situations that could have been much worse than the actual outcome.

• Department

• Date and Time of incident

  Date

• Please write all that apply: Unsafe Act, Unsafe Condition, Unsafe Equipment, Unsafe use of Equipment, Equipment fail

• Who was involved ?

Investigation Information

• Description of the event:

• Causes (primary & contributing)

• Corrective action taken (remove the hazard, replace, repair, or retrain in the proper procedures for the task)

• Signature & Date

  Sign

• Management

  Sign