Near Miss Report V4.0

• Document No.

• Audit Title

• Client / Site

• Prepared by

PLEASE COMPLETE THE NEAR MISS SECTION BELOW

• Site Details:

• Near Miss Witnessed?

Near Miss
• Location:
  Address

• What Happened? (Please Detail the 'Near Miss' You have Witnessed):

• When? (Time & Date):

  Date

• Photographic Evidence Before:

  Media

• Tell Us the Current Status of the Near Miss:

  RECTIFIED AT THE SCENE

  UNABLE TO RECTIFY

• Photographic Evidence After:

  Media

• Tell us what you have done to Remove the Risk?

• WARNING - PLEASE NOTIFY THE SITE MANAGER OR ACTING SUPERVISOR IMMEDIATELY.

• Has the Supervisor been Informed?

  YES

  NO

• Who have you Informed?

• How Were they Informed?

  Select Telephone Email Text In Person

  • Telephone
  • Email
  • Text
  • In Person

• NOTIFY A SUPERVISOR IMMEDIATELY

SUBMITTED BY

• THE NEAR MISS REPORT MUST BE EMAILED DIRECT TO THE CLIENT AND CORSAN OFFICE @ claire.kilby@corsan.co.uk

• Please Inform Us of Your Status?

  CORSAN OPERATIVE

  VISITOR

• Print & Sign:

  Sign