Near Miss Report Form

• 1. You must report any Near Miss that occurs in the workplace using this form.

• 2. Once the report is completed, please email directly to your direct line manager and SHEQ Manager.

• Project Number

• Project Title

• Date Near Miss reported

  Date

• Incident Report No. (To be completed by SHEQ Manager)

• Name of Employee involved (optional):

• Near Miss Defined
  HSE defines 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:

  Date
• Location of Near Miss. If customer site, please provide address
  Address

• Select the category the near-miss most relates to:

  Select Behavioural PPE Poor Supervision Heat, Sparks, Flame Slip Trip / Fall on same level Fall from height Fall from equipment Flying/Falling Object Access & Egress Plant & Equipment (Mechanical, Collision) Hazardous Manual Handling Electric Shock/Hazard Caught between/underneath Hazardous Substance Falling object Other Environmental Issues Noise, Dust, Lighting & Material Storage COSHH, Spillage, leaks of material or Liquid Lack of Training

  • Behavioural
  • PPE
  • Poor Supervision
  • Heat, Sparks, Flame
  • Slip
  • Trip / Fall on same level
  • Fall from height
  • Fall from equipment
  • Flying/Falling Object
  • Access & Egress
  • Plant & Equipment (Mechanical, Collision)
  • Hazardous Manual Handling
  • Electric Shock/Hazard
  • Caught between/underneath
  • Hazardous Substance
  • Falling object
  • Other
  • Environmental Issues
  • Noise, Dust, Lighting & Material Storage
  • COSHH, Spillage, leaks of material or Liquid
  • Lack of Training

• If Other, please state:

• Describe how the Near Miss occurred (include the body part and type of pain if applicable):

• Describe what lead up to and caused the Near Miss. Identify root causes:

What happened?

• Explain what happened in as much detail as possible.

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What went wrong?

• Explain what went wrong in as much detail as possible.

• undefined

What were the causes?

• Explain what the root cause of the

• What was learned and changed due to the Near Miss?

• Yes

  No

  N/A

• Photo/s that can help explain the what, where, why, or the possible injury:

  Media

• Name and Signature (optional)

  Sign

• Give full details on the remedial and future actions took/to be taken

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• Name of person closing out the report.

• Sign:

  Sign

• Date:

  Date