Near Miss Report
Initial Details
To be completed in the event of an incident, a major non-conformance, unsafe practice or a near miss that could have resulted in a serious injury or illness.
Was an injury suffered?
No
Yes (if Yes, you must complete an "Incident Report" not this "Near Miss Report")
Tile
Reference
State
Please Select
QLD
NSW
VIC
TAS
NT
SA
WA
Near Miss reported by?
Reporter Details
First Name
Last Name
Address
Phone Number
Email
example@example.com
About the Near Miss
Where did it happen?
Site Address
Site Reference (Customer Name)
When did it happen?
-
Month
-
Day
Year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
What happened?
Has the area, structure or plant been made safe?
Yes
No
Photo of damage, hazard and or solution
Browse Files
Drag and drop files here
Choose a file
Cancel
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Was there a Witness?
Witness Name
First Name
Last Name
Additional Information
Submit
Should be Empty: