2 Minute Near-Miss Report Form
Location:
Date / Time
Check Appropriate Box:
RED (Stop Work and Report)
YELLOW (Use Caution and Report)
GREEN (Continue and Report)
Description:
Unsafe Act
Unsafe Equipment
Unsafe Condition
Unsafe use of Equipment
Description of Near Miss:
Reported by (Optional):
First Name
Last Name
Signature (Optional):
Submit
Should be Empty: