Near Miss Report Form

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Site Manager

• Contract Manager

Personal Details

• Operatives Involved

• Occupations:

  Select Machine Operator Plant Operator Groundworker Visitor Sub-Contractor Member of the Public Other

  • Machine Operator
  • Plant Operator
  • Groundworker
  • Visitor
  • Sub-Contractor
  • Member of the Public
  • Other

• Activity being conducted:

Near Miss Details

• Date of Incident:

  Date

• Site Address:

Near Miss Circumstances

• Description of Events:

• Machinery / Equipment Involved:

Damage Details

• Any equipment, property or other damage:

Witness Details

• Were there any witnesses to the near miss?

  Yes

  No

  N/A

• Name of witnesses

• Have witness statements been obtained from all witnesses?

  Yes

  No

  N/A

• Witness statements to be completed

Completion

• Signature:

  Sign

• Date:

  Date