NEAR MISS Reporting Form NEAR MISS Reporting Form

Type of Near Miss:  Hot surface  Slippery floors  Trip over extension line Type of Near Miss:  Hot surface  Slippery floors  Trip over extension line
 Forklift  Falling Object  Bad practice  Others.  Forklift  Falling Object  Bad practice  Others.
Please describe__________________ Please describe__________________
Date of Incident: Time of Incident: Date of Incident: Time of Incident:

Location: Injuries? Yes / No Location: Injuries? Yes / No

Persons Involved in Near Miss Incident: Persons Involved in Near Miss Incident:
Names Department/ Company Contact Number Names Department/ Company Contact Number

Other Witnesses: Other Witnesses:

Names Department/ Company Contact Number Names Department/ Company Contact Number

Briefly describe what happened including the sequence of events. Safety & Compliance Manager and JH & S Briefly describe what happened including the sequence of events. Safety & Compliance Manager and JH & S
Committee will investigate scene of incident or near miss; conditions present at time of incident; what was involved, what activity (if any) Committee will investigate scene of incident or near miss; conditions present at time of incident; what was involved, what activity (if any) was
was taking place prior and at time of incident. What hazards was the worker exposed to? What hazards may have contributed to the incident taking place prior and at time of incident. What hazards was the worker exposed to? What hazards may have contributed to the incident
occurring? (Attach photos if available) occurring? (Attach photos if available)

Near Miss Incident #________________ Near Miss Incident #________________

NEAR MISS Investigation Form NEAR MISS Investigation Form

What preventative action should have been taken? Why was this action not taken? What preventative action should have been taken? Why was this action not taken?

What contributing factors were there? (Lack of experience, adverse conditions, etc.) What contributing factors were there? (Lack of experience, adverse conditions, etc.)

Recommendations Resulting from Investigation Recommendations Resulting from Investigation

#1- #1-

#2 #2

#3 #3

Recommendation # Person Responsible Completion Date Review Date Recommendation # Person Responsible Completion Date Review Date

EHS Department Signature Date EHS Department Signature Date

Near Miss Incident #_______________ Near Miss Incident #_______________