NEAR-MISS REPORT FORM
Employee completing this form
First Name
Last Name
Department and Location of Near miss:
Department/Division
Building/Work Area or Jobsite
Date and time of Near Miss:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Describe the Near-Miss including any events leading to or immediately following the Near-Miss. What happened?
Describe how the incident could potentially result 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:
Witness Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Submit
Should be Empty: