Near Miss Report

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