Near Miss Report

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

Near Miss Report

• Time and date of incident

  Date

• Location of incident

• Persons involved

• Person making report,

• and in what capacity

• Description of events:

• Was this a:

• Near Miss - incident occurred where someone could have suffered an injury or damage to the environment - e.g something fell and did not hit anyone!

  Yes

  No

  N/A

• Unsafe Act - where someone was undertaking work in an unsafe manner - e.g. improper use of a mobile tower / steps etc - Not wearing the correct PPE for the works - NO P2W for works being undertaken.

  Yes

  No

  N/A

• Unsafe condition - where it was identified that there is an issue on site which could cause an accident - scaffold not secured to prevent unauthorised access? site not secure - Mobile tower not erected properly etc.?

  Yes

  No

  N/A

• Immediate cause of incident

• Environment (e.g. weather conditions, slippery floor etc)

• Actions arising / recommendations suggestions

• By whom / responsibility

• Signed:

  Sign

Copies to: