Near Miss Reporting V2.0

• Document No.

• Audit Title

  Near Miss Notification

• Client

  Wates Living Space

• Site

  Chevin Homes

  St Leger Homes

  CESP

  Oldham PFI

• Conducted on

  Date

• Prepared by

  David Burns

  Gavin Burns

  Mark Dannatt

  Paul Carrick
• Location
  Address

PLEASE COMPLETE THE NEAR MISS SECTIONS BELOW

• Site Details:

  Chevin Homes

  St Leger Homes

  CESP

  Oldham PFI

• Add Near Miss

Notification

• What Happened (Please detail the Near Miss that you have Witnessed):

• Please include Photographic Evidence:

  Media

• When (Time/Date):

  Date

• Supervisor Informed?

  Yes

  No

  N/A

• Thank you for reporting this near miss. Now we know about it, we can do something to avoid an accident in the near future. All reports submitted will be reviewed by Wates Supervision and where appropriate, action taken to remove or minimise risk. (Comments by The Manager):

• Submitted By:

  Sign

• Please inform us of your Status:

  Employee of Corsan

  Sub Contractor to Corsan

  Visitor