Information
-
Near Miss Report No.
-
Conducted on
-
Employee Name (optional):
-
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.” -
Location of Near Miss. If customer site, please provide address
-
Date & Time of Near Miss:
-
Photo/s that can help explain the near miss:
-
Please explain the near miss that occurred:
-
Stop work or work business as usual?
-
Name and Signature (optional)
