Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • At which plant did this occur?

  • Enter the date and time of the near miss

  • Enter the name(s) of the employee involved

  • Enter the exact location that the near miss occurred (B-Cut, Loading Station)

  • Photo of location

  • List any equipment that was involved

  • Photo of equipment involved

  • Was proper PPE being worn? (If no, explain why)

  • Was company policy being followed? (If no, explain why)

  • Description of the near miss

  • Was a root cause analysis performed? (If no, explain why)

  • List any corrective actions, disciplinary actions, extra training, etc. that is required due to the near miss

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.