Construction Forms

Near Miss Report

When to complete: A near incident is an unplanned event that did not result in injury, illness, or damage, but had the potential to do so.

In case of emergency call 911

Company Code*

Date of Near Incident*

Near Incident Time*

Branch*

Date Near Incident Reported*

Address/Location of Near Incident*

City*

State*

Zip*

Description of Near Incident*

Photos Related to Description

Employee Printed Name*

Employee Signature*

Branch Manager/Supervisor Printed Name

Branch Manager/Supervisor Signature

Can be completed later if supervisor is not available

Employee/Driver Making Report (Your Name)*

Home/Cell Phone*

Unit Number/License Number

Contractor/Customer (Who You Are Working For)

Phone#

Describe what could have happened if the near incident had resulted in an actual incident

Photos Related to What Could Have Happened

Describe corrective actions taken or recommended to prevent this from happening again

Photos Related to Corrective Actions

Name & Address

Phone

Name & Address

Phone

All Supporting Documentation Sent to Safety Dept

Select