Near Miss Report
Time Near Miss Incident Was Reported to Safety Manager
Please use 24-hour time
Person Filling Out This Form
First Name
Last Name
Date of Near Miss
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Job Name
Please list the full names of all employees involved.
Please specify what kind of personal protective equipment (PPE) was involved.
Please describe the details of the incident.
Please provide suggestions as to how this kind of near miss could be prevented in the future.
Has/have the hazard(s) been eliminated?
Yes
No
Please upload any photos or documents relevant to the near miss below.
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