Near Misses Register Appropriate conditions:

1. Unsafe Act
Project: ……………… Address: …………………………… 2. Unsafe Condition
Month: / 2013 3. Unsafe equipment

Date - Appropriate Potential Corrective Date

No Location Person/ Company What happened? Done
Time conditions Hazard Action taken Completed
O
1

O
2

O
3

O
4

O
5

O
6

O
7

O
8

O
9

Reported by: ……………………………………… Signature: ………………………