NEAR MISS REPORT

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.

"*" indicates required fields

DATE OF NEAR MISS/INCIDENT*

LOCATION OF NEAR MISS/INCIDENT (OFFSITE - CUSTOMER, ROAD. LYNCH’S - OFFICE, GARAGE, YARD)*

Incident reference number*

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

PERSON(S) INVOLVED*

First Name Last Name

DESCRIPTION OF THE NEAR MISS/INCIDENT*

WHAT INJURY, LOSS OR DAMAGE COULD POTENTIALLY HAVE OCCURRED?*

COULD ADDITIONAL CONTROL MEASURES BE INTRODUCED TO PREVENT A RECURRENCE OF THE NEAR MISS/INCIDENT?*

PERSON COMPLETING THIS FORM*

First Name Last Name