Near Miss Report

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Near Miss Report

• A near miss is a potential hazard or incident that has not resulted in any personal injury. Unsafe working conditions, unsafe employee habits, improper use of equipment or use of malfunctioning equipment have the potential to cause work related injuries. It is everyone's responsibility to report and/ or correct these potential accidents/incidents immediately. Please complete this form as a means to report these near-miss situations.

• Department/ Location

• Time of incident

• Please select all that apply:

  Select Unsafe Act Unsafe Condition Unsafe Equipment Unsafe Use of Equipment

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

• Description of incident or potential hazard:

• Picture of Incident

  Media

• Employee Signature & Date

  Sign

Near Miss Investigation

• Description of the near-miss condition:

• Causes (primary & contributing)

• Corrective action taken (remove the hazard, replace, repair, or retrain in the proper procedures for the task)

• Signature & Date

  Sign

• Management

  Sign