Near Miss Report

• Site conducted

  Select

• Conducted on

  Date

• Reported by

• Location
  Address

Background Information

• Job site

• Job description

• Add person(s) involved

Person

• Name of person involved

• Title/ Position of person involved

• Supervisor name

• Supervisor contact number

• Were there any witnesses?

  Yes

  No

• Primary witness name

• Primary witness number

Incident Details

• Date and time of incident

  Date
• GPS location of where incident occured
  Address

• Description of where incident occured (e.g. 2nd floor)

• Near-Miss Description (Select all that apply)

  Select Unsafe Act Unsafe Condition Unsafe Equipment Unsafe Use of Equipment Other

  • Unsafe Act
  • Unsafe Condition
  • Unsafe Equipment
  • Unsafe Use of Equipment
  • Other

• Provide details

• Supporting photos of near miss

  Media

• Personal Protective Equipment (PPE) used?

  Yes

  No

• Why was it not being used

• List PPE used

Recommendations

• Corrective Actions - What should be done or has been done to prevent this incident? (examples: employee training, change of procedures, purchasing of equipment etc.)

• Name of responsible party for corrective actions

• General observations

Sign Off

• Signature of person who completed form

  Sign

• Supervisor review

  Sign