Near Miss Report

• HSE define a near miss as an “ An event not causing harm, but has the potential to cause injury or ill health''

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Near Miss Report

• Department/ Location

• Time of incident

• Please write all that apply: Unsafe Act, Unsafe Condition, Unsafe Equipment, Unsafe use of Equipment

• Description of incident or potential hazard:

• Picture of Incident

  Media

• Employee Signature & Date

  Sign

Near Miss Investigation

• Description of the near-miss condition:

• Causes (primary & contributing)

• Corrective action taken (remove the hazard, replace, repair, or retrain in the proper procedures for the task)

• Signature & Date

  Sign

• Management

  Sign