Please provide address, specific location, customers name, below

Location of Near Miss being Reported

Team Members Name:

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

Description of immediate corrective actions

5 why analysis

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.