NEAR MISS REPORT – OFFICE USE

A near miss is an unplanned event which has not resulted in injury, illness or damage. The incident could however have had the potential to result in injury, illness, loss or damage and therefore the reporting of such incidents will assist in the monitoring of risks and enable the company to add additional control measures where applicable. Please note, where actual injury has occurred an Accident Report Form should be completed.

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DATE OF NEAR MISS/INCIDENT*

Incident reference number*

Person involved initials and date in DDMMYYYY format, i.e LT01012025

PERSON(S) INVOLVED*

First Last

IS THERE A REQUIREMENT FOR ANY ADDITIONAL TRAINING?*

DOES THE RISK ASSESSMENT FOR THE TASK/AREA INVOLVED REQUIRE TO BE REVIEWED/UPDATED?*

OTHER MEASURES TO BE TAKEN*

REVIEWED BY MANAGEMENT*