Title Page

  • Conducted on

  • Reported by

  • Location

Background Information

  • Job site

  • Job description

  • Add person(s) involved

  • Person
  • Name of person involved

  • Title/ Position of person involved

  • Supervisor name

  • Supervisor contact number

  • Were there any witnesses?

  • Primary witness name

  • Primary witness number

Incident Details

  • Date and time of incident

  • GPS location of where incident occured
  • Description of where incident occured (e.g. 2nd floor)

  • Near-Miss Description (Select all that apply)

  • Provide details

  • Supporting photos of near miss

  • Personal Protective Equipment (PPE) used?

  • Why was it not being used

  • List PPE used

Recommendations

  • Corrective Actions - What should be done or has been done to prevent this incident? (examples: employee training, change of procedures, purchasing of equipment etc.)

  • Name of responsible party for corrective actions

  • General observations

Sign Off

  • Signature of person who completed form

  • Supervisor review

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.