Near Miss Reporting Form

• Please use this form for reporting all Near Miss or Close Calls.
  Gather as much information as possible and photograph where possible.
  Notify Kylie or Andrew via email once form has been completed so it can be logged correctly.

• Date report is completed:

  Date

• Person reporting:

• Role or Position in the Company:

• Name of affected employee:

• Their role or position in the company:

• Date and time when the near miss occurred:

  Date
• Site/location of the near miss:
  Address

• Where exactly in the site/location did the near miss occur? (the specific area, room, floor, or building)

• What hazard/s triggered the near miss?

• Detailed description of the near miss: Include relevant events leading up to, during, and after the near miss. This information should come from the affected employee.

• Add photo(s) where possible to show hazard

  Media

• Names of eye witnesses:

• Their role/s or position/s in the company:

• Description of the near miss from eye witnesses: Include relevant events leading up to, during, and after the near miss.

• Names of employees who were in the specific area, room, floor, or building at the time of the near miss, but did not see the near miss occur (yet were aware that it was happening):

• Their role/s or position/s in the company:

• Description of the near miss from these employees: Include relevant events leading up to, during, and after the near miss.

Identifying Root Causes

• What caused or allowed the near miss to happen?

• What were the specific factors?

• Were safety procedures being followed?

  Yes

  No

  N/A

• Why were they not being followed?