RCK Near Miss Report

• Conducted on

  Date

• Prepared by

• Near Miss Location
  Address
• Exact Location On Site
  Address

• On Site Point of Contact

• The reason for investigating an incident or near miss is to determine: the cause or causes of the incident. to identify any risks, hazards, systems or procedures that contributed to the incident; and to recommend corrective action to prevent similar incidents.
  
  Incidents should be investigated by people knowledgeable about the type of work involved at the time of the incident. Relevant workers should also be involved in the investigation.
  
  An incident /near miss investigation report should answer the WHO, WHERE. WHEN, WHAT. WHY and HOW questions with regard to an incident.

Section 1 - Details of Near Miss

• Date and Time of Near Miss

  Date

• Person Involved & Role

• Person Involved & Role

• Witness(es) - Name, Job Title (If relevant), Contact Number

• Description of the Near Miss

Section 2 - Immeadiate/Contributing Causes - That may have been a factor

• What Preventative Action Could Have Been Taken?

• Why Was This Action Not Taken?

• Employee Experience?

• What Training Relevant to the Task Has The Employee Received?

• Were They Appropriately Supervised?

• Outline Actions to Prevent a Similiar Situation Occurring Again?

Sign Off

• Completed By

  Sign

• Date Completed

  Date