Falewitch

Near Miss Report / Safety Concern

Review of a near miss incident or safety concern

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Use this Template

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Information

Document No.
Audit Title
Client / Site
Conducted on
Prepared by

Explain in detail any "Safety Concern" or "Near Miss" (include what, when, and where):
Photographs of situation observed, damage sustained, etc.
Location
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

Falewitch

Near Miss Report / Safety Concern

Review of a near miss incident or safety concern

Use this Template

Print as PDF

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