NEAR-MISS REPORT FORM
A near-miss is a potential hazard or incident that has not resulted in any personal injury or property damage. In each of the sections below, please describe what happened, the background and any hazardous materials,equipment or processes involved in the incident. Please indicate what could have potentially happened if conditions developed into a more serious situation. Include how to prevent this from recurring.
Employee / Person completing this form.
First Name
Last Name
In which location do you work?
Please Select
Administration
Haulout
Member
On-Water
Wardroom / Galley
Other
Location of the Near- Miss:
Please Select
Car Park
Haulout
Heads / Showers
Office
On-Water
Ramp
Rigging Lawn
Storage Area
Wardroom / Galley
Other
Date of Near Miss:
-
Day
-
Month
Year
Date
Describe the Near-Miss including any events leading to or immediately following the Near-Miss. What happened:
Describe how the incident could potentially resulted in a serious or life-threatening situation. What could have happened:
Please indicate how the incident can be prevented from reoccurring again:
Please provide any other comments below:
Thank you for your participation. Please note that this form will be reviewed by NPCL management and you will receive a response.
Should be Empty: