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NEAR MISS REPORT
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Name: (Optional)
First
Last
Witness (Optional)
Date / Time of the Incident:
*
Date
Time
detail appropriate was
Building / Work Area:
*
Mark all appropriate conditions:
*
Near-miss
Safety concern
Safety suggestion
Other (Describe below)
Type of concern:
*
Unsafe act
Unsafe condition of area
Unsafe condition of equipment
Unsafe use of equipment
Other (Describe below)
Describe the potential incident/hazard/concern and possible outcome (in as much detail as possible):
*
Were safety procedures violated? (describe)
*
Safety Suggestions:
Incident site inspection – Why was an unsafe act committed, or why was the unsafe condition
*
Recommendations/steps to take to prevent a similar
*
Date Reported
*
Submit
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