Information

  • Site conducted

  • Incident Report No.

  • Conducted on
  • Report Completed by :

  • Instructions:
    1. Required to be completed when you experience Near Miss Incident in the workplace
    2. To be completed in full and emailed to SHEQ Manager or the ESS Head Office.

  • The HSE defines a near miss as an event that doesn't cause harm but has the potential to. near miss: an event not causing harm, but has the potential to cause injury or ill health You have probably experienced a near miss before. They happen more often than you might think

  • 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)

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.