The Near Miss Form Template UK is offered in multiple formats, including PDF, Word, and Google Docs, and features editable and printable versions for your convenience.
Near Miss Form Template UK Editable – PrintableSample
Near Miss Form Template UK 1. Incident Information 2. Reporting Person Information 3. Description of Near Miss 4. Contributing Factors 5. People Involved 6. Immediate Actions Taken 7. Recommendations 8. Follow-up Actions 9. Review and Analysis 10. Management Review 11. Declaration and Signatures
PDF
WORD
Examples
[Date of the Near Miss]
[Specific Location of Incident]
[Name of the Person Reporting]
[Employee ID]
[Job Title]
[Detailed description of the near miss, including what happened, and potential hazards involved.]
[Names and Contact Information of any witnesses to the incident.]
[Description of any immediate actions taken post-incident to ensure safety.]
[Analysis of what could have happened if the near miss had escalated into an actual incident.]
[Suggestions on how to prevent similar near misses in the future, including modifications to processes, training, or equipment.]
[List any follow-up actions that need to be taken, including deadlines and responsible persons.]
[Signature of Person Reporting]
[Date of Reporting]
[Date of the Near Miss]
[Specific Location of Incident]
[Name of Person Reporting]
[Employee ID]
[Supervisor’s Name]
[In-depth explanation of the incident, outlining how the near miss occurred and the context of the situation.]
[List of witnesses with their contact details, if applicable.]
[Outline of steps taken immediately after the near miss took place to mitigate further risk.]
[Assessment of the risks associated with the near miss and how they will be evaluated moving forward.]
[Details on what changes or improvements are suggested to prevent a recurrence of a similar incident.]
[Specific action items that must be completed following the incident and responsible personnel for each item.]
[Signature of Supervisor]
[Date of Signature]
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