Information
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Client
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Site
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Date the Report was completed
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Name of the individual that has reported the “Near Miss” - (Optional).
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Report Completed by:
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Position of the Person carrying out this Report:
Near Miss Investigation Report Information
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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 line manager or the Health & Safety Manager. -
Near Miss Defined
OSHA and the National Safety Council defines a near miss as an “unplanned event that did not result in injury, illness or damage – but had the potential to do so.” -
Date & Time that the “Near Miss” occurred:
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Location of “Near Miss”. If on a customer site, please provide the full address.
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Precise location where the “Near Miss” occurred
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Select the category that the “Near Miss” most relates to:
- Fall from height
- Trip / Fall on same level
- Fall from equipment
- Manual Handling
- Electric Shock
- Caught between/underneath
- Hazardous Substance
- Falling object
- Other
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Describe the events leading up to the moment that the “Near Miss” occurred:
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What “Preventative Actions” are to be implemented?
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What “Corrective Actions” have been carried out?
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Were any injuries sustained to either individuals, surfaces or property?
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Root Cause Analysis
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Further Comments
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Name and Signature of the person signing off the “Near Miss” Investigation Reportm
