NEAR MISS REPORT

Bao Cao Tai Nan Tiem An

Project: Date:
Ten d an: Ngay:
Contractor: No:
Nha thau: So:

Tick
Location and Time an
Criteria Involved/ Tieu Chuan Lien Quan
V tr va Thi Gian
h
- Personal protective equipment/ Trang b vat dung bao - dau
Task (Noi Dung): ho -
- Loading , moving materials/ Boc d/ di chuyen vat lieu -
- Support / hanging device/ Thiet b, dung cu treo, boc d -
- Security/ Bao ve -
- Fire/ He thong cha chay -
Date (Ngay): - Electrical connections / system He thong ket noi ien -
- Machinery: welding, burning, rotating device, etc. -
Time (G): May moc: han, ot, thiet b xoay, v. v -
- Chemical / corrosion Hoa chat/ an mon -
- Others Khac -

Factual Statement/ Trnh bay thc te

Immediate Action Required/ Further action suggested/

Hanh ong thc te yeu cau Hanh ong khac e ngh

Witnessed by Owner Approved by Consultant Requested by Contractor

(Chng kin ca Ch u t) (Ph duyt ca T vn) ( ngh t Nh thu)

Name (Tn): Name (Tn): Name (Tn):

Position (Chc v): Position (Chc v): Position (Chc v):

Revision 00 HSE-16
Page 1 of 1