Near miss incident report - duplicate

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Identification of near miss

• Name of employee(s) involved:

• Date and time of near miss:

  Date

• Date and time near miss was reported:

  Date

• Location of near miss:

  Select plant two plant three R10 B1 B17 plant one Red fox Yard

  • plant two
  • plant three
  • R10
  • B1
  • B17
  • plant one
  • Red fox
  • Yard

• Facility of near miss:

  Corrpro

  TBC

  BPPC

  United

Description of how near miss occurred:

• Add media

  Media

Nature of damage to property:

• Add media

  Media

Cause of damage to property?

• Select Act Condition Defect

  • Act
  • Condition
  • Defect

• Explain:

Remedy for prevention:

Witness statements:

• Person completing report:

  Sign

• Supervisor signature:

  Sign