Title Page

  • Document No.

  • We want you to work safely. To reduce the possibility of injury we are encouraging you to report near misses/hazards/close calls.

    By letting us know, we may be able to prevent injury to someone else!

  • Identified by:

  • Conducted on

  • Location


  • Hazard/Near Miss/Close Call?

  • Category

  • You have selected a low risk category - Continue with the activity once approved PPE, actions and controls in place

  • You have selected a medium risk category - Continue if you are competent and authorised to put corrective procedures in place

  • You have selected a high risk category - if you cannot eliminate cause of near miss, STOP and seek guidance!

  • Classify near miss type (high risk):

  • Description of Near Miss/Hazard

  • Action Taken

  • Photos

  • Closed?

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.