NEAR MISS INVESTIGATION TEMPLATE

• Conducted on

  Date

• Prepared by

• Type of hazard

• Location of hazard

• Description of hazard

• Add media

  Media

• Immediate action

• Add media

  Media

Prevent action

• Action

• Date

  Date

• Owner

• Status

  Completed

  Pending

  In progress

Corrective action

• Action

• Date

  Date

• Owner

• Status

  Completed

  Pending

  In progress

• Hierarchy of Risk

  Select ELIMINATION SUBSTITUTION ISOLATION ENGINEERING ADMINISTRATIVE PERSONAL PROTECTIVE EQUIPMENT

  • ELIMINATION
  • SUBSTITUTION
  • ISOLATION
  • ENGINEERING
  • ADMINISTRATIVE
  • PERSONAL PROTECTIVE EQUIPMENT

Closing by

• Name

• Date

  Date

HSE Review

• Name

• Date

  Date

• Yes

  No

  N/A