Near-Miss Event Reporting Form (Maritime)
Event Details
Date of Event
Time of Event
Location
Vessel Name
Department
Deck
Engine
Catering
Other
Individuals Involved
Names (if known)
Rank/Position
Description of Near-Miss
Describe What Happened
Potential Consequences (if not avoided)
Immediate Actions Taken
Actions Taken
Suggested Corrective Action / Preventive Measures
Suggestions
Reporter Information
Name
Rank/Position
Report Date