NEAR MISS REPORT

• Conducted on

  Date

• Prepared by

• Location
  Address

WORKS LOCATION DETAILS

• LCRA Borough PERMIT no

• Works Team Name / Reference

• Team Leader's Name:

• NGE Site Controller Name

NEAR MISS DETAILS

• NEAR MISS Subject - Health & Safety

  Select

• Near Miss Subject Environmental

  Select

• Other Topic

CLOSE OUT REPORTING

• Suggestions / Actions / Reflections?

• Picture of NEAR MISS if available ( MAX 3 PICTURES)

  Media

• Removal / Reporting

  Select

• SIGNATURE

  Sign

Sheet