Information
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Incident Report No.
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Conducted on
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Employee Name (optional):
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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 misses are less severe than accidents. However, near misses should not be ignored or treated lightly, as they can provide valuable insight into how well you are managing health and safety in your workplace - HSE -
Date & Time of Near Miss:
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Location of Near Miss. If customer site, please provide address
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People involved
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Select the category the near-miss most relates to:
- Work at Height
- Work Equipment
- Hot Works
- Slip, Trip or Fall
- Hazardous Substance
- Hazardous Manual Handling
- Electric Shock
- Caught between/underneath
- Other
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Describe what lead up to and caused the Near Miss. Identify root causes:
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Describe how the Near Miss occurred (include the body part and type of pain):
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Photo/s that can help explain the what, where, why, or the possible injury:
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What was learned and controls implemented due to the Near Miss?
