6601079Hokuala_Near Miss Report

NEAR MISS REPORT FORM

1. Secure the Scene

2. Collect the Facts

3. Description/Develop the Sequence of Events

4. Signoff and Final Report
STEP 1 - SECURE THE SCENE
STEP 2- COLLECT THE FACTS:
Project Name
Incident Location
Brief Summary of Incident
Provide a brief description of the near miss & possible outcome
Company Reporting Incident
Reported To
Reported By
Date of Occurrence

MonthDayYear
Date
Time of Occurrence

Hour Minutes

AM/PM Option
Date Reported

MonthDayYear
Date
Time Incident Reported

Hour Minutes

AM/PM Option
Were there any witnesses
If so, how many
COLLECT THE FACTS
Company involved in near miss
Superintendent/Foreman Involved with Near Miss
Worker Involved with Near Miss
Type none if not known or not applicable
Foreman Involved with Near Miss PCL only
Select what the outcome would have been if it was not a Near Miss
Did the incident involve another trade contactor
If yes, Trade Contractor's Company
Trade Contractor Superintendent Name
Describe the sequence of events that led to the Near Miss incident
Name

First NameLast Name
Signature
Should be Empty: