Near Miss Report

Department/ Location:

Date / Time of Incident *

Date

Time

Hazard (copy) Contributing)

Please Check All Appropriate Conditions:

Unsafe Act
Unsafe Condition
Unsafe Equipment
Unsafe Use of Equipment

Please Select Who Was Involved: *

Internal Employee or Environment
Subcontractor

Subcontractor Name (if applicable):

Description of Incident or Hazard *

Description of Incident or Hazard (copy) *

Causes (Primary & Contributing) *

Corrective Action Taken (Remove the Hazard, Replace, Retrain, Etc) *

Upload a Photo

Click or drag files to this area to upload.You can upload up to 10 files.

Name *

First

Last

By submitting this form with your first and last name, counting as your electronic signature, you are claiming the information provided in this form to be true based on you witnessing the above reported near miss.

Date of Submission *

Near Miss Report

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