• Site conducted

  • Incident Report No.

  • Conducted on

  • Employee Name:

  • 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 supervisor and the Safety Director

  • 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.