Al Naboodah Construction Group LLC

Document Reference
ANCG-HSE-FRM-003
Rev. No.

NEAR MISS REPORT

Rev. Date

01

08/15

Page

1 of 1

Date & Time

Project/Location
Personnel
Involved/Witnesses

Description of incident
or potential hazard

What could have resulted

Immediate cause

Root or Contributing
Cause

Corrective action

Preventative action

Recommendation for
continual improvement

Name:
CC: HSE Manager

Designation:

ID No:

Signature: