Near Miss Report - Blakes Cross/M1/Huntstown

• Site conducted

  Blakes Cross

  M1

  Huntstown

• Conducted on

  Date

• Prepared by

• Location of Near Miss (take picture)

  Media

• Who identified the near miss?

• Please describe what was identified

• Please take a picture of the hazard

  Media

• Have you notified your line manager

  Yes

  No

• Why not?

  Yes

  No

• Have you spoken to the person/persons displaying unwarrented behaviour

  Yes

  No

Facilities

• Is action required by facilities?

  Yes

  No

  N/A

• What is required?

  Yes

  No

  N/A

Quality, Health and Safety and Environment

• Is action required by Quality, Health & Safety and Environment?

  Yes

  No

  N/A

• What action is required?

  Yes

  No

Additional Notes

• Have you any additional items to add

• Is training required as a result of this?

  Yes

  No

Report Sign Off

• Date and Time

  Date

• Signature

  Sign

• Notify Supervisor

  Yes

  No