Near Miss Report 1.0

• Project name and job number.

• Location
  Address

• Incident occurred on

  Date

• Incident reported on:

  Date

• Incident investigated on:

  Date

• Investigated by

Near Miss Report

• Picture of Incident

  Media

• Please check appropriate boxes for all that apply:

• Unsafe Act

• Unsafe Condition

• Unsafe Equipment

• Unsafe Use of Equipment

• Description of incident or potential hazard:

• Employee signature

  Sign

Near Miss Investigation

• Description of the near-miss condition:

• Causes (primary & contributing)

• Corrective action taken (remove the hazard, replace, repair, or retrain in the proper procedures for the task)

• Signature & Date

  Sign

• Management

  Sign