Construction Incident Near Miss Report
Project & Reporter Details
Project Name
Location
Date
Time
Reported By
Position/Title
Incident Details
Describe the Near Miss
People Involved (if any)
Witnesses (if any)
Work Activity at Time
Risk Assessment
Potential Outcome if Not Avoided
Hazard Type
Fall
Equipment
Chemical
Electrical
Other
Prevention & Controls
Immediate Action Taken
Proposed Preventive Measures
Follow Up
Supervisor/Manager Notified
Date Investigated
Additional Notes