Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Type of Near Miss

  • Choose one....

Description of Near Miss

  • Take a photo? (optional)

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

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

Signature (optional

  • Team Member Signature

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

Action taken by Commitee

  • Safety Committee Reviewed Report

  • Committee Recommendation...

  • Employee Co-Chair

  • Management Co-Chair

  • Store Manager Review

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.