Information
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Document No.
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Conducted on
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Employee Name (optional):
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Instructions:
1. Required to be completed when you experience a Safety Near Miss in the workplace
2. To be completed in full and emailed to direct manager or the Health & Safety Manager. -
Near Miss Defined
Near miss is a “unplanned event that did not result in injury, illness or damage – but had the potential to do so.” -
Date & Time of Near Miss:
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Location of Near Miss. If customers site, please provide address
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Select the category the near-miss most relates to:
- Fall from height
- Trip / Fall on same level
- Fall from equipment
- Hazardous Manual Handling
- Electric Shock
- Caught between/underneath
- Hazardous Substance
- Falling object
- Other
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Describe how the Near Miss occurred (include the body part and type of pain if any):
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Describe what lead up to and caused the Near Miss. Identify root causes:
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What was learned and changed due to the Near Miss?
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If a photo will help explain the what, where, why, or the injury upload the picture here:
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Choose your level of anonymity for this near miss report
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By my signature below I attest that the information I have provided is true and accurate to the best of my knowledge:
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Signature:
