• Incident Report No.

  • Conducted on

  • Employee Name (optional):

  • Instructions:
    1. Required to be completed when you experience a Safety Near Miss in the workplace
    2. To be completed in full and emailed to direct manager or the Health & Safety Manager.

  • Near Miss Defined
    near miss: an event not causing harm, but has the potential to cause injury or ill health

  • Date & Time of Near Miss:

  • Location of Near Miss. If customer site, please provide address
  • Select the category the near-miss most relates to:

  • Describe how the Near Miss occurred (include the body part and type of pain):

  • Describe what lead up to and caused the Near Miss. Identify root causes:

  • What was learned and changed due to the Near Miss?

  • Photo/s that can help explain the what, where, why, or the possible injury:

  • Name and Signature (optional)

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