Near Miss Incident Report

Near Miss Incident Report



General Information

1. Date and time of the Incident.


Photo Comment

2. Location (please be as accurate as possible).


Photo Comment
Details Of Person Reporting

1. First Name


Photo Comment

3. Category of Person – staff, student, contractor or visitor


Photo Comment

4. If other, give more details


Photo Comment

5. Name of the contractor (if applicable)


Photo Comment
Incident Details

1. Description of the Incident


Photo Comment

2. Describe what happened?


Photo Comment

3. What immediate actions were taken at the time?


Photo Comment

4. List additional actions which could be taken to prevent a similar occurrence?


Photo Comment

5. Photograph(s) of the area and/or results of the near-miss or incident




Upload
Photo Comment

6. Additional comments / observations


Photo Comment

Is this sample what you are looking for?
Sign up to use & customise this template, or create your own custom checklist:

Checklist by GoAudits.com – Please note that this checklist is intended as an example. We do not guarantee compliance with the laws applicable to your territory or industry. You should seek professional advice to determine how this checklist should be adapted to your workplace or jurisdiction.

goaudits app

Get started on a free trial

Seeing is believing! Try the full platform FREE for 14 days with your own data.
Or ask us to setup the system for you, at no cost.

GoAudits Logo

Is GoAudits right for you?

Trusted by 600+ businesses globally

Book Intro Call