PCL
NEAR MISS REPORT FORM
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
Location
Project Name
PSI Done:
Y
N
Risk Classification:
A Fatality
B Serious
C injury
Type
Injury
Illness
Environmental
Equipment/Property
Company Involved
Superintendent Involved
Worker Involved
Shift Hrs:
Hour Minutes
AM
PM
AM/PM Option
to
Hour Minutes
AM
PM
AM/PM Option
Division of Work
Work Activity
Description of Event: What, How, Who, Time, When
Immediate Action(S) Taken
Suggestions to Prevent Similar Occurrence / Corrective Actions
1.
2.
3.
4.
Root Cause
Lead investigator Print
Print Name
Lead investigator
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preview PDF
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