Near Miss Report

• Project name

• Conducted on

  Date

• Prepared by

• Location
  Address

Section 1: Details of near miss

• Describe the Near Miss

• Location of the Near Miss

• Conditions at the Time

Section 2: Personnel Involved

• Names of Individuals Involved

• Witnesses

Section 3: Potential Consequences

• - What Could Have Happened?

• - Severity Rating:

Section 4: Immediate Actions Taken

• - Actions Taken to Prevent Immediate Hazard:

Section 5: Root Cause Analysis

• - Identify the Root Cause(s):

• - Contributing Factors:

Section 6: Corrective and Preventative Actions

• - Corrective Actions:

• - Preventative Measures:

• - Responsible Person(s):

• - Target Completion Date:

Section 7: Review and Follow-Up

• Reviewed By:

• Review Date:

  Date

• Follow-Up Actions:

• Follow-Up Completion Date:

  Date

Section 8: Signatures

• Signature of Person Reporting:

  Sign

• Signature of Supervisor/Manager:

  Sign