Near Misses Form

Near Misses Form

Date

Please select a date.

Time

Please select a time.

Report Type

Unsafe Acts & Conditions

Hazard

Incident/Accident

Work Group

Please enter a work group.

Location

Please enter a location.

Department

Please enter a department.

Number of People

Please enter the number of people.

What Happened

Please describe what happened.

Action Taken

Please describe the action taken.

Further Action Required

Reported By

Please enter the name of the reporter.

Supervisor

Please enter the name of the supervisor.

Status

Pending

Ongoing

Suspended

Completed