NEAR MISS INCIDENT REPORT FORM

Document No. SJCPL-HSE-FR-22 Effective date

Project: Date of Incident reported:

Work section/exact location: Date of occurrence:
Time of occurrence: Reported to:
Witnessed by: Reported by:
Potential injury to:
SJCPL Emp. Contractor Emp. Third Party Ass. Company
Nature of potential injury:
Equipment Damage Personal injury Fire/ Explosion Motor Vehicle Other

Details if required:

Activity:
Nature of occurrence:

Cause: Strike which one is correct

Immediate Cause Contributing Factors
Failure to wear PPE Unsafe Act
Failure to follow rules, procedures Unsafe condition
Poor housekeeping Unsafe Environmental factors
Horse play Hazardous method of working
Bypassing safety devices Defective equipment
Working on dangerous equipment/place Hazardous arrangement
Improper use of equipment Unsafe human behaviour
Failure to Secure Unsafe personal factors
Failure to warn
Recommendations to prevent re-occurrence:

Actions taken:

Report prepared by: Designation: Site Safety Incharge

Signature: Date: