Explain in detail any "Safety Concern" or "Near Miss" (include what, when, and where):

Photographs of situation observed, damage sustained, etc.


Your suggestions on how to improve this situation would be greatly appreciated: (Optional)

I have corrected the "Safety Concern" / "Near Miss"

How has it been corrected?

Photographs of corrected items.
Date & Time Reported
Name of individual reporting
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.