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  • Near Miss Report

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    Borislav Vulić
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    This near miss report documents an incident that occurred on a construction project. It provides details of the incident including location, description of what happened, identified causes, and recommendations to prevent future occurrences. A supervisor and witness provided statements. The incident was evaluated and the report distributed to project management and safety personnel for review.

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    This near miss report documents an incident that occurred on a construction project. It provides details of the incident including location, description of what happened, identified causes, and recommendations to prevent future occurrences. A supervisor and witness provided statements. The incident was evaluated and the report distributed to project management and safety personnel for review.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    165 views2 pages

    Near Miss Report

    Uploaded by

    Borislav Vulić
    This near miss report documents an incident that occurred on a construction project. It provides details of the incident including location, description of what happened, identified causes, and recommendations to prevent future occurrences. A supervisor and witness provided statements. The incident was evaluated and the report distributed to project management and safety personnel for review.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
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    of 2

    NEAR MISS REPORT

    NM Ref. No.(CRC/YYYY/MM/SN):____________________________ Date:


    ______________________
    Project Title: Contract / CRC No.:

    Supervisor / Foreman (Name & Emp. No.): Witness (Name & Emp. No.):
    ________________________________ _________________ ________________________________ _________________
    Employee(s) Involved (Name & Emp. No.): Property Involved (If Assess Potential:
    Any): LOW
    ________________________________ _________________
    ________________________________ _________________ MEDIUM
    ________________________________ _________________
     HIGH
    INCIDENT DETAILS
    Date: Time: Location:

    A.M. P.M.
    Near Miss Description (Explain what happened)
    ___________________________________________________________________________________________________________
    ___________________________________________________________________________________________________________
    ___________________________________________________________________________________________________________
    ___________________________________________________________________________________________________________
    _________________________________________________________________________________________________
    _________________________________________________________________________________________________________
    Cause(s) of the Near Miss (What caused it to happen)
    ___________________________________________________________________________________________________________
    ___________________________________________________________________________________________________________
    ___________________________________________________________________________________________________________
    ___________________________________________________________________________________________________________
    _________________________________________________________________________________________________
    Recommendation (To prevent recurrence and future accidents)
    __________________________________________________________________
    __________________________________________________________________
    __________________________________________________________________
    __________________________________________________________________ Signature of Witness
    __________________________________________________________________
    __________________________________________________________________
    __________________________________________________________________
    __________________________________________________________________ Signature Supervisor/Foreman
    __________________________________________________________________
    Evaluation & Conclusion (Review and conclude the incident)
    __________________________________________________________________
    __________________________________________________________________
    __________________________________________________________________
    __________________________________________________________________ Signature of PM / PIC
    __________________________________________________________________
    DISTRIBUTION: Project Manager HSE Manager Supervisor / Foreman Originator
    * All High Risk Incident Reports must be sent to CEO.
    NOTE: 1. To be filled by the witness, Supervisor / Foreman.
    2. Orally notify HSE Manager & Project Manager / Project in-charge immediately.

    Revision No. 01 Page No. 1 of 1 Doc. No. IS-HSE-R53


    Prepared by: Management Representative Issued Date: 21st January 2018
    Reviewed by: General Manager Approved by: Chief Executive Officer
    3. This form to be duly completed, signed and sent within 24 hours.

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