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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)

Quick Near Miss Form Checklist

Created by: SafetyCulture Staff | Industry: General | Downloads: 54

Use this near miss form to quickly record the incident and indicate of work stopped or continued business as usual.

Signup for a free iAuditor account to download and edit this checklist. It will be added to your free account and you will be able to conduct inspections from your mobile device.

Download and edit this free checklist

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Audit

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)