Form: Near-miss notification - Sunborn Intranet

NEAR MISS REPORT

A near miss situation at the workplace refers to an incident where a more serious accident did not occur, but the situation could have led to an accident.

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Workplace *

Department *

DESCRIBE THE FOLLOWING DETAILS AS ACCURATELY AS POSSIBLE:

Date of the incident *

Exact location of the incident? *

What happened? *

Conditions at the time of the incident? *

What led to the near miss situation? *

Could the situation have been prevented? How? *

Have any measures been taken in the department to prevent future accidents? *

Describe the measures taken below. *

Who performed the measures? *

Describe how the measures will proceed and the timeline. *

Who initiated the measures? *

Upload the file as an attachment to the report.

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

You can upload up to 3 files if necessary. The maximum size for a single file is 12 MB. Allowed file formats are Word, PowerPoint, Excel, PDF. Images (png, .gif, .jpg) and videos (.mpg, .mov, .wmv) are also allowed.

NAME AND CONTACT INFORMATION OF THE REPORT SUBMITTER:

First and last name *

Phone number *

E-mail

NEAR MISS REPORT

DESCRIBE THE FOLLOWING DETAILS AS ACCURATELY AS POSSIBLE:

NAME AND CONTACT INFORMATION OF THE REPORT SUBMITTER:

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