Near Miss Template

• Site conducted

  Select

• Near Miss Report No.

• Conducted on

  Date

• Employee Name:

• Employee Job Title:

• 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 your Manager or Supervisor for comment.

• Near Miss Defined
  HSE defines a near miss as an event not causing harm, but has the potential to cause injury, ill health or create a dangerous occurrence

• Date & Time of Near Miss:

  Date

• Please state Location of Near miss e.g House / Flat number, Communal Area etc

• What action did you take?

  Stop work and report

  Use Caution and report

  Continue and report

• Please categorise the type of Near Miss

  Unsafe Act

  Unsafe Equipment

  Unsafe Condition

  Unsafe Use of Equipment

• Describe the near miss:

• Photo/s (optional):

  Media

• Names of other witnesses:

• Reporting person's Name and Signature: (Optional)

  Sign

• Yes

  No

  N/A

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• Add location
  Address