Near Miss Investigation Report

• Conducted on

  Date

• Prepared by

• Location
  Address

• Site

  Glasgow

  Basildon

  Poland

• Near miss title and No

• Near Miss Description

• Did you take any actions at time of Near Miss

  Yes

  No

• Describe action and outcome

• How did the action taken work

  Good

  Fair

  Poor

  N/A

• Visual Evidance

  Media

Implementation of Change

• Is there a practicable change that could be implemented

  Yes

  No

• Description of change including documents and method of distributing information

Review Change

• Review date of implimentation

  Date

• Is implementation complicated and successful

  Yes

  No

• Add new evidence and information to implement

• Visual Evidance

  Media

• Date and time for revew

  Date

Close investigation

• H&S signature to close off

  Sign