VEEGRIP BELTS PVT LTD

Document Ref. : F-HR-NMR

Revision No : 00'
Revision Date : 05-06-2023
Edition No : 00'
NEAR MISS REPORT Edition Date : 05-06-2023
Page : 1 OF 1

This form should be completed by any employee who witnesses a near miss incident, such as collapsing
shelves, items falling from height, charred or burnt electrical equipment or furniture, or a slip on a slippary
surface, where the person did not actually fall. Heads of Department may complete the form on behalf of the
person who witnessed the near-miss.

For Office use only

Name : S.No:
Designation / Department :
Location of Near-miss :
Date of Near-miss :
Time of Near-miss :
Please describe the near-miss which you witnessed below:

Names of any other witnesses:

Signature:………………………………………………….. Date:……………………………………….