NEAR MISS REPORT
A Near Miss is an incident having the potential for causing injury to an employee or the
general public, or causing damage to Customer or Company property. This program is
not designed to place blame but to enable others to recognize and identify hazards
before they become incidents.
Date of Near Miss:
Time of Near Miss:
Date reported:
Reported to whom:
Your name:
Location of Near Miss:
Brief Description of the Near Miss:
What was the cause of the Near Miss?
What could be done to prevent a recurrence of the Near Miss?
Signature of Person Reporting:
Date Signed:
____________________________________
____________________
Turn in completed Near Miss Report to either the Safety Director or your Safety
Representative
Ops Plus, Inc.  4530 Bishop Lane, 109
 Louisville, Kentucky 40218
 Phone (502) 454-9767  Fax (502) 454-3563