NEAR MISS REPORT

A near miss is potential hazard or incident that has not resulted in any personal injury. Unsafe working conditions, unsafe employee work habits, improper use
of equipment or use of malfunctioning equipment have the potential to cause work related injuries. It is everyone’s responsibility to report and / or correct
these potential accidents / incidents immediately.

Name of Project: Near Miss Report No: Date:

Location on site: Time: Hrs

CHECK ALL APPROPRIATE CONDITIONS

◻ Unsafe Act ◻ Unsafe equipment
◻ Unsafe Condition ◻ Unsafe use of equipment
DESCRIPTION

Name: Designation Signature

NEAR MISS INVESTIGATION

DESCRIPTION OF THE NEAR-MISS CONDITION

CAUSE (PRIMARY & CONTRIBUTING)

PROPOSED CORRECTIVE / PREVENTIVE ACTION

(Removing the hazard, replace, repair, or retrain in the proper procedures for the task)

Report Prepare by: Head of department / C. OH&S Manager

Document number here Page 1 of 2
Name: Name:

Signature: Date: Signature Date:

TO BE CLOSED AFTER IMPLEMENTATION OF CORRECTIVE / PREVENTIVE ACTION (VERIFIED)

Date of closing: Name / Title: Signature:

Lost Time: Man-hours:

(time lost due to suspension of work, analysis of non-conformity, implementation of corrective & preventive action

Document number here Page 2 of 2