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Near Miss Report

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Location

Department

Date of near miss

Time of near miss

Description of near miss.
(Please give as much detail as possible.)

Upload an image of the near miss

Optional. JPG, PNG or WebP. Maximum file size: 5 MB.

Reported by *
Please enter your full name.

Reported to *
Please enter their full name.

Please tick all appropriate conditions

Unsafe actUnsafe conditionUnsafe equipmentUnsafe use of equipment

Investigation and Corrective Actions

Outcome / investigation of the event

Investigation undertaken by
Please enter the line manager's full name.

Corrective action taken

Please tick all that apply.

Remove the hazardReplace equipmentRepair equipmentProvide retrainingReview procedures for the task

Manager responsible for implementing corrective actions

Date actions completed

Actions completed

Has feedback been given to the person who raised the near miss?

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Near Miss Report

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