O2 Near Miss Reporting

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Type of Near Miss

• Choose one....

  People

  Property

  Product

Description of Near Miss

• Take a photo? (optional)

  Media

• Did I do something to fix the Near Miss? If so, what?

  Yes

  No

  N/A

• Suggestions on how to prevent re-occurrence...

  Yes

  No

  N/A

Signature (optional

• Team Member Signature

  Sign

• Do you want to get a Reply from the Safety Commitee

  Yes

  No

  N/A

Action taken by Commitee

• Safety Committee Reviewed Report

  Yes

  No

  N/A

• Committee Recommendation...

  Yes

  No

  N/A

• Employee Co-Chair

  Sign

• Management Co-Chair

  Sign

• Store Manager Review

  Sign