Daily site assurance

Near-Miss Reporting Form

Report the event, its potential consequences, and any corrective action taken so it doesn't happen again.

Basic information

Fields marked * are required

Department / Project * Location of near miss * Date of near miss * Time of near miss * Reported by (name & designation) *

What happened? (briefly describe the event) * What could have happened? (potential consequences if not avoided)

Select at least one *

If "Other", specify

Immediate actions taken to prevent recurrence

Was the hazard eliminated? If no, specify required actions to eliminate the hazard

To be completed by the HSE Manager or investigation team, if known

Investigation lead (name & designation) Date of investigation

Lack of Awareness/Training Inadequate Supervision Equipment/Tool Defect Procedural Failure Time Pressure/Workload Other

If "Other", specify

Detailed description of root cause

Corrective actions

Preventive measures

Person responsible for action Target completion date

Reported by (signature & date) * HSE Manager (signature & date)

Follow-up conducted by (name & designation) Follow-up date

Status of corrective actions If not completed, reason

JPEG, PNG, or WEBP · up to 8 photos · 8 MB each

Near-miss reportSubmit for review by the HSE team