Background Information

Job site

Job description

Add person(s) involved


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


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
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.