Title Page

  • Conducted on

  • Prepared by

  • Location
  • Site

  • Near miss title and No

NearMiss

  • Near Miss Description

  • Did you take any actions at time of Near Miss

  • Describe action and outcome

  • How did the action taken work

  • Visual Evidance

Implementation of Change

  • Is there a practicable change that could be implemented

  • Description of change including documents and method of distributing information

  • Review Change
  • Review date of implimentation

  • Is implementation complicated and successful

  • Add new evidence and information to implement

  • Visual Evidance

  • Date and time for revew

Close investigation

  • H&S signature to close off

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.