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Instructions:
1. Required to be completed when you experience a Safety Near Miss in the workplace
2. To be completed in full and emailed to direct manager or the Health & Safety Manager.

Near Miss Defined
OSHA and the National Safety Council defines a near miss as an “unplanned event that did not result in injury, illness or damage – but had the potential to do so.”

Date & Time of Near Miss:
Location of Near Miss:

Describe the near miss:

Photo/s (optional):

Names of other witnesses:

Reporting person's Name and Signature:

Near Miss Template Checklist

Created by: SafetyCulture Staff | Industry: General | Downloads: 87

This near miss template allows providing the description and photos surrounding the incident as well as inclusion of the names of other witnesses of the near miss.

Signup for a free iAuditor account to download and edit this checklist. It will be added to your free account and you will be able to conduct inspections from your mobile device.

Download and edit this free checklist

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Audit

Instructions:
1. Required to be completed when you experience a Safety Near Miss in the workplace
2. To be completed in full and emailed to direct manager or the Health & Safety Manager.

Near Miss Defined
OSHA and the National Safety Council defines a near miss as an “unplanned event that did not result in injury, illness or damage – but had the potential to do so.”

Date & Time of Near Miss:
Location of Near Miss:

Describe the near miss:

Photo/s (optional):

Names of other witnesses:

Reporting person's Name and Signature: