Near Miss Report
Construction
Safety
A near miss is an unplanned event that threatens human safety or health, the environment, or the continued normal operation of the business enterprise, wherein the last protective barrier is challenged, but defeated. Use this near miss form to report a near miss incident.
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Near Miss Report Audit

Date & Time of Near Miss:
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Location of Near Miss. If customer site, please provide address
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Select the category the near-miss most relates to:
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Describe how the Near Miss occurred (include the body part and type of pain):
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Describe what lead up to and caused the Near Miss. Identify root causes:
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What was learned and changed due to the Near Miss?
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Photo/s that can help explain the what, where, why, or the possible injury:
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Name and Signature (optional)
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