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Quick Near Miss Form

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Quick Near Miss Form

Audit

Instructions: 1. Required to be completed when you experience a Safety Near Miss in the workplace 2. To be completed in full and emailed to direct manager or the Health & Safety Manager.
Near Miss Defined OSHA and the National Safety Council defines a near miss as an “unplanned event that did not result in injury, illness or damage – but had the potential to do so.”
Location of Near Miss. If customer site, please provide address
Date & Time of Near Miss:
Photo/s that can help explain the near miss:
Please explain the near miss that occurred:
Stop work or work business as usual?
Name and Signature (optional)
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