Near Miss Report

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.
NoYes (If Yes, you must complete an "Incident Report" not this "Near Miss Report")
Person Involved in Near Miss
Person involved

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Near Miss Reported By:
Near Miss Reported by:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
About the Near Miss:

Where did the near miss occur?
Incident Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
When did the Incident happen?

DayMonthYear
Date
Time
What Happened?
YesNo
Photo of damage, hazard or solution

Cancelof
YesNo
Witness Name

First NameLast Name
Additional Information:
Should be Empty:

Person Involved in Near Miss