Near Miss / Improvement Opportunity Initial Report

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Personnel

Classification

• Select ALL those that apply

  Select Health Safety Environment

  • Health
  • Safety
  • Environment

Details of the Incident

• Outline details of the event (include all relevant information)

Completion

• Name

• Position

• Add signature

  Sign