Near Miss Reporting Form Template UK

The Near Miss Reporting Form Template UK is offered in several formats, including PDF, Word, and Google Docs, featuring customizable and printable samples.

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Sample

Near Miss Reporting Form Template UK

Editable – Printable

PDF – 1 PDF – 2

Near Miss Reporting Form Template UK

1. Reporter Information



2. Incident Details


3. Description of the Near Miss

4. Contributing Factors

5. Immediate Actions Taken

6. Witness Information

7. Recommendations for Prevention

8. Additional Comments

9. Declaration


PDF

WORD

Examples

Near Miss Reporting Form Template UK (1)
Reported By:
[Name of the Reporter]
[Employee ID]
[Department]
[Contact Information]
Date of the Incident:
[Date]
Time of the Incident:
[Time]
Location:
[Specific Location of the Incident]
Description of the Near Miss:
[Detailed account of the near miss incident, including what happened, any potential hazards, and the circumstances surrounding the event. Include any injuries that could have occurred. Be as thorough as possible.]
Persons Involved:
[List names and roles of all individuals involved, if applicable.]
Potential Consequences:
[Discuss the possible outcomes had this near miss resulted in an accident, including impacts on individuals, operations, and overall safety.]
Immediate Actions Taken:
[Describe any immediate actions taken to mitigate the risk or manage the situation following the near miss, such as first aid, reporting to authorities, or securing the area.]
Recommended Preventive Measures:
[Provide suggestions on how to prevent similar incidents in the future, including training, policy changes, or equipment upgrades.]
Signature of the Reporter:
[Signature]
[Date]
Near Miss Reporting Form Template UK (2)
Reported By:
[Name of the Reporter]
[Employee ID]
[Department]
[Contact Information]
Date of the Incident:
[Date]
Time of the Incident:
[Time]
Location:
[Specific Location of the Incident]
Description of the Near Miss:
[In-depth description of the near miss incident, elaborating on how the event unfolded and what factors contributed to the near miss. Encompass all relevant details.]
Involved Personnel:
[Document all individuals involved in or witnesses to the incident along with their respective roles.]
Potential Risks:
[Outline the risks that could have resulted from the near miss, detailing possible injuries, liabilities, or operational disruptions.]
Actions Taken Responding:
[Explain the actions taken immediately following the incident to address any immediate danger or injury, including any notifications made to supervisors or safety officers.]
Future Recommendations:
[Suggest actionable recommendations focused on improving safety and preventing recurrence, considering both policy adjustments and employee training opportunities.]
Signature of the Reporter:
[Signature]
[Date]

Printable

PDF – 1 PDF – 2

Near Miss Reporting Form Template UK