Location of Near Miss
Date and Time of Near Miss

Please provide details of what was observed

Please provide photos of the site (where applicable)
What type of activity was being undertaken?

Contractor/Technicians Name and Company

Please record actions taken on site/Conversation held on site.

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.