Near Miss Report Form
Employee Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Project Name
*
Risk Classification
*
A
B
C
Date of Incident
*
-
Month
-
Day
Year
Date
Time of incident
*
Hour Minutes
AM
PM
AM/PM Option
Date Reported
*
-
Month
-
Day
Year
Date
Time of incident reported
*
Hour Minutes
AM
PM
AM/PM Option
Area Location
*
Witnesses (If yes please provide statement with report)
*
Yes
No
Company Involved
*
Superintendent Involved
Worker Involved
PSI Completed
*
Yes
No
Shift Starting Time
*
Hour Minutes
AM
PM
AM/PM Option
Shift End Time
*
Hour Minutes
AM
PM
AM/PM Option
Weather Conditions
*
Level of Lighting In Area
*
Work Activity
*
Scheduled Work Activity Type
*
Did the incident involve another Trade Contractor
*
Yes
No
Company Name
Superintendent Name
What could have been the potential outcome?
*
Injury
Illness
Environmental
Environmental Spill
Equipment/Property Damage
Description of the Event (Include photos drawings diagrams to help provide a clear understanding of the event)
*
List immediate actions taken below
1
2
3
4
Preview PDF
Submit
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