Near Miss / Safety Share

• Conducted on

  Date

• Reported by

• Location
  Address

Background Information

• Job description

• Add person(s) involved

Person

• Name of person involved

• Title/ Position of person involved

• Were there any witnesses?

  Yes

  No

• Primary witness name

• Primary witness number

Details (What was the near-miss or what needs to be shared)

• Date and time of near miss

  Date
• Location of where incident occurred
  Address

• What Happened?

• Near-Miss Description (Select all that apply)

  Select Unsafe Act Unsafe Condition Unsafe Equipment Unsafe Use of Equipment Other

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

• Provide details

• Supporting photos of near miss

  Media

Recommendations

• Corrective Actions - What should be done or has been done to prevent this incident? (examples: employee training, change of procedures, purchasing of equipment etc.)

• Name of responsible party for corrective actions

• General observations