Near Miss Report Form
Employee Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Project Name
*
Date of Near Miss
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Near Miss
*
Hour Minutes
AM
PM
AM/PM Option
Date Reported
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time Near Miss 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
Weather Conditions
Work Activity
What could have been the potential outcome?
*
Injury
Illness
Environmental
Environmental Spill
Equipment/Property Damage
Description of the Event
*
List immediate actions taken below
1
2
3
4
Preview PDF
Submit
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