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

• 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

• Were there any witnesses? if so attach statement to investigation form

  Yes

  No

  N/A

• Severity Rating?

  Select

• Surface condition?

  Select Good Fair Poor N/A

  • Good
  • Fair
  • Poor
  • N/A

• Lighting?

  Good

  Fair

  Poor

  N/A

• Noise?

  Safe

  At Risk

  N/A

• Weather Conditions?

  Good

  Fair

  Poor

  N/A

• Is a risk assessment required?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Explain why a risk assessment is not required

• Has a risk assessment be reviewed?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Has the current risk assessment been communicated?

  Yes

  No

  N/A

• Were those trained to carry out the tasks? Attach training records to investigation.

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Were the appropriate PPE, work equipment and procedures being used and/or followed?

  Select Yes No N/A

  • Yes
  • No
  • N/A

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

• Signature & Date

  Sign

• Management

  Sign