Near Miss Report Form

• Site

• Date of Report

  Date

• Date and Time of Near Miss

  Date
• Location of Near Miss
  Address

• Witnesses

• Report By

• Supervisor

• INSTRUCTIONS
  
  1. Please provide responses on the questions below.
  2. Take a photo by clicking on the "Add Media Button"
  3. To add a Corrective Measure click on the paperclip icon then "Add Action", provide a description, assign to a member, set priority, and due date
  4. Complete audit by providing digital signature
  5. Share your report by exporting as PDF, Word, Excel or Web Link.

• Near Miss
  
  An event that had the potential to cause harm or injury to people, property or the environment
  Completed Near Miss report forms must be submitted to your Project Manager or Health & Safety Coordinator on the same day as near miss occurred, by 6pm.

Details of Incident

• Type of Near Miss Report

  Select • Personal • Environmental • Equipment Failure • Property Damage

  • • Personal
  • • Environmental
  • • Equipment Failure
  • • Property Damage

• Nature of Near Miss

• Work Carried Out

• Name(S) of Person Involved

• PERSON

• Please specify Name

• Describe how the near miss occured

• Upload an image

  Media

• What was the immediate cause of the event

• Upload an image

  Media

• Basic or root cause of the event

• Upload an image

  Media

General Comments and Observations

• Please add additional comments and observations

Completion

• Reporting Employee Name and Signature

  Sign

• Supervisor Name and Signature

  Sign