NEAR MISS REPORT Report No:

GENERAL INFORMATION
1. Location 2. Department/Project 3. Team/Supervisory Team*:
Office
Field
4. Incident Type: 5. Date of Incident: 6. Time of Incident:

Near Miss [dd-mm-yyyy] [hh-mm]

Significant Near Miss 7. Incident Location or Area:

8. Incident Identified by:

Name of Identifier: Team of Identifier:

INCIDENT DETAIL INFORMATION

9. Job Purpose: 10. Equipment Used:
Specific Task: Specific Equipment:

11. Incident Short Description:

INCIDENT ANALYSIS
12. Investigation and Root Cause Analysis Result (for Significant Near Miss):
Causal Factor Root Cause

RECOMMENDATIONS
13. In order to prevent recurrence:

1 2 3
Indentifier Dept.Head/Party chief HSE Officer/PM or OM

THIS REPORT TO BE USED ONLY FOR PT MAHAKARYA GEO SURVEY INTERNAL BUSINESS PURPOSE.

Distribution : Team Concern

*project only
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