Near Miss/Risk Observation Report

• Site conducted

  Select

• If your site is not listed please list it here

• Conducted on

  Date
• Location
  Address

• Reference Number

• Name (or you can remain anonymous and continue to answer the questions)

Falling Object

• Falling Object

• How serious is the close call (on a scale of 1-10, 10 being very serious)

• Brief description of the close call/near miss

• Exact location of the close call/near miss

• What corrective action was taken to make the area safe

• After any immediate corrective action how serious is the close call (on a scale of 1-10, 10 being serious)

Slip Trip Fall

• Slip Trip or Fall

• How serious is the close call (on a scale of 1-10, 10 being very serious)

• Brief description of the close call/near miss

• Exact location of the close call/near miss

• What corrective action was taken to make the area safe

• After any immediate corrective action how serious is the close call (on a scale of 1-10, 10 being serious)

Housekeeping

• Housekeeping

• How serious is the close call (on a scale of 1-10, 10 being very serious)

• Brief description of the close call/near miss

• Exact location of the close call/near miss

• What corrective action was taken to make the area safe

• After any immediate corrective action how serious is the close call (on a scale of 1-10, 10 being serious)

Restricted Access

• Restricted Access

• How serious is the close call (on a scale of 1-10, 10 being very serious)

• Brief description of the close call/near miss

• Exact location of the close call/near miss

• What corrective action was taken to make the area safe

• After any immediate corrective action how serious is the close call (on a scale of 1-10, 10 being serious)

Working at Height

• Working at Height

• How serious is the close call (on a scale of 1-10, 10 being very serious)

• Brief description of the close call/near miss

• Exact location of the close call/near miss

• What corrective action was taken to make the area safe

• After any immediate corrective action how serious is the close call (on a scale of 1-10, 10 being serious)

PPE

• PPE

• How serious is the close call (on a scale of 1-10, 10 being very serious)

• Brief description of the close call/near miss

• Exact location of the close call/near miss

• What corrective action was taken to make the area safe

• After any immediate corrective action how serious is the close call (on a scale of 1-10, 10 being serious)

Manual Handling

• Manual Handling

• How serious is the close call (on a scale of 1-10, 10 being very serious)

• Brief description of the close call/near miss

• Exact location of the close call/near miss

• What corrective action was taken to make the area safe

• After any immediate corrective action how serious is the close call (on a scale of 1-10, 10 being serious)

Lifting Operations

• Lifting Operations

• How serious is the close call (on a scale of 1-10, 10 being very serious)

• Brief description of the close call/near miss

• Exact location of the close call/near miss

• What corrective action was taken to make the area safe

• After any immediate corrective action how serious is the close call (on a scale of 1-10, 10 being serious)

Confined Space

• Confined Space

• How serious is the close call (on a scale of 1-10, 10 being very serious)

• Brief description of the close call/near miss

• Exact location of the close call/near miss

• What corrective action was taken to make the area safe

• After any immediate corrective action how serious is the close call (on a scale of 1-10, 10 being serious)

Excavations

• Excavations

• How serious is the close call (on a scale of 1-10, 10 being very serious)

• Brief description of the close call/near miss

• Exact location of the close call/near miss

• What corrective action was taken to make the area safe

• After any immediate corrective action how serious is the close call (on a scale of 1-10, 10 being serious)

Environment

• Environment

• How serious is the close call (on a scale of 1-10, 10 being very serious)

• Brief description of the close call/near miss

• Exact location of the close call/near miss

• What corrective action was taken to make the area safe

• After any immediate corrective action how serious is the close call (on a scale of 1-10, 10 being serious)

Plant and Equipment

• Plant and Equipment

• How serious is the close call (on a scale of 1-10, 10 being very serious)

• Brief description of the close call/near miss

• Exact location of the close call/near miss

• What corrective action was taken to make the area safe

• After any immediate corrective action how serious is the close call (on a scale of 1-10, 10 being serious)

Vehicles

• Vehicles

• How serious is the close call (on a scale of 1-10, 10 being very serious)

• Brief description of the close call/near miss

• Exact location of the close call/near miss

• What corrective action was taken to make the area safe

• After any immediate corrective action how serious is the close call (on a scale of 1-10, 10 being serious)

Utilities

• Utilities

• How serious is the close call (on a scale of 1-10, 10 being very serious)

• Brief description of the close call/near miss

• Exact location of the close call/near miss

• What corrective action was taken to make the area safe

• After any immediate corrective action how serious is the close call (on a scale of 1-10, 10 being serious)

Other

• Other

• How serious is the close call (on a scale of 1-10, 10 being very serious)

• Brief description of the close call/near miss

• Exact location of the close call/near miss

• What corrective action was taken to make the area safe

• After any immediate corrective action how serious is the close call (on a scale of 1-10, 10 being serious)

• Thank you for completing the Near Miss/ Hazard Report Form