Reference Number
TSR/II/002
Implementation Date
03.12.2018
Revision / Amendment Number
0
Revision / Amendment Date
03.12.2018
NEAR MISS REPORT
Site
Near miss Number
Details of the Near miss (What, Where, When)
Short description of near miss
Task being performed at the time
Area where near miss occurred
Date of incident
Time of incident
Details of the near miss investigation (Whom)
Name of employee or process
Job description employee (if applicable)
Qualification/Certificate and or design of
process or employee available.
Name of person who reported incident
Date of report
Name of person leading investigation
Near miss Investigation (why)
Investigator Recommendations
Corrective Action
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Reference Number
TSR/II/002
Implementation Date
03.12.2018
Revision / Amendment Number
0
Revision / Amendment Date
03.12.2018
NEAR MISS REPORT
Acknowledgment
Responsible employee (if
Applicable)
Name & Surname
Signature
Date
Supervisor
Name & Surname
Signature
Date
Manager
Name & Surname
Signature
Date
Safety Personnel
Name & Surname
Signature
Date
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