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NEAR MISS REPORT
HEALTH AND SAFETY PROGRAM
Project Name:
*
Location:
*
Date of the near miss
*
-
Month
-
Day
Year
Date
Date Reported
*
-
Month
-
Day
Year
Date
Supervisor:
*
Time:
*
Reporting Employee (Name Optional):
*
Please explain the near miss or unsafe condition below in detail: Details:
*
Please note the corrective action:
*
Check if apply
*
Power tools Failure
Falling tools
Fire hazard
Electrical hazard
Tripping/slippery
Property damage
Other
Employee Signature
*
Supervisor email
example@example.com
Supervisor Signature
*
Date
*
-
Month
-
Day
Year
Date
TO BE COMPLETE BY MANAGMENT
H&S Email
example@example.com
Health and Safety Rep.
Date received by Health & Safety
-
Month
-
Day
Year
Date
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