Near Miss Report Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Near Miss Report Form

• Name of the person making this report

• Employee Number

• Name of the person directly involved in the incident if different

• Employee Number

• You may leave this section blank & submit the report anonymously but this may impair the reviewers ability to make effective judgements or recommendations.

Incident Details

• Incident date & time

  Date

• Location

• Precise nature of the near miss event

• In your view what could have be done to prevent a reoccurrence?

• Witness details

• Estimate risk for potential injury or accident damage

  1 = Low

  2 = Low to Medium

  3 = Medium

  4 = Medium to High

  5 = High

• Has this near miss been reported to line management, customer or site operator?

  Yes

  No

• If yes who?

• Signed

  Sign