This document is a near miss report card used to report safety concerns. It asks the user to mark the level of concern as red, yellow, or green and provides areas to note the location, date, time, and type of concern whether an unsafe act, condition of area/equipment, or equipment use. The back of the card allows for a description of the near miss and optional reporting party details.

1. Mark all appropriate concern:
Near Miss Safety Concern Safety Suggestion Other (Describe)
Near Miss Report Card
Location Date Time
Red
Stop Work and Report
Yellow
Use Caution and Report
Green
Rectified - Safe and Report
Report on the back side of the card
Type of Concern:
Unsafe Act Unsafe Condition
of Area
Unsafe Condition
of the equipment
Unsafe use
of Equipment
Others (Describe)

2. Description of Near Miss
Reported by (Optional)
Name: Signature:
Near Miss Report Card