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NEAR-MISS
REPORT
Client Name
Site Name
Filled By
Near Miss Location
Please check the box that describe the situation.
Safety*
Moving Machinery
Moving Vehicle
Manual Handling
Fall from a Height
Harmful Substance
Explosion
Welfare
Buried Services
Hand Tools Powered
Collapsed Excavation
Site / Office Security
Falling from Height
Hit Something Fixed/Stationary
Slipped Tripped Fell at Same Level
Something Collapsing/Overturning
Fire
Electricity
Lifting Operations
Overhead Services
Hand Tools Manual
PPE Non Compliance
Live Traffic
Environment*
Discharge To Water / Sewer
Fuel / Chemical Spill or Leak
Extreme Weather
Waste Storage / Disposal
Fumes / Odours / Dust
Carbon Emission
Brief Description of Incident
