Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Please provide address, specific location, customers name, below

  • Location of Near Miss being Reported
  • Team Members Name (optional)

  • Supervisors Name:

  • Serious Injury Fatality (S.I.F.) ?

  • Serious Injury Fatality S.I.F. (Precursors)

  • Type of Near Miss being reported ?

  • *If other please list in here

  • Description of Near Miss being reported:

  • Insert photograph of Near Miss being reported here (please remember confidentiality and no TMs faces)

  • Description of immediate corrective actions

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.