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 a txt sent to Rochelle to let her know there is a near miss to look into -
Near Miss Defined
A near miss as an “unplanned event that did not result in injury, illness or damage – but had the potential to do so.” -
Date & Time of Near Miss:
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Location of Near Miss. If customer site, please provide address
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Describe how the Near Miss occurred :
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Describe what lead up to and caused the Near Miss. Identify root causes:
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What was learned and changed due to the Near Miss?
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Photo/s that can help explain the what, where, why:
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Name and Signature (optional)
