NEAR MISS REPORT
INCIDENT DETAILS
Project:
Date: Time: Location/Plant/Equipment:
Near Miss Description (Explain What happened – Use attachment if needed.
ESTIMATE OF LOSS POTENTIAL (What injuries or losses might have occurred)
Injuries:
Property/Equipment Damage:
Environmental Damage:
Other:
ANALYSIS (Why did it happen (List unsafe acts, unsafe conditions, wrong procedures/equipment or other factors)
CORRECTIVE ACTION (What must be done to prevent recurrence – List recommendations)
REVIEWER INFORMATION
Reviewed by Supervisor or above (Name / Title / Badge):
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