MADHURE INFRA ENGINEERING PVT. LTD.

MIEPL/SAF/F-39

NEAR MISS INCIDENT REPORT (NMIR)

NM Sr. No:
Project: Location: Date & time

Personal details:
1) Name of the person involved:
Underlying causes:
2) Age & Sex:
1
3) Trade/ designation:
2
4) Name of the contractor:
3
5) Work
Immediate experience:
action taken (Isolation/ segregation/correction, etc.):
16) Plant & Equipment involved:
27) Exact location of the Incident:
3
Incident details & actions:
4
Description of incident (how it occurred?)
Investigation team:
Sr.
Name Designation Signature
No.

1 Project Head

2 Project EHS Coordinator/officer

3 Site engineer
Why why analysis?
4 Supervisor
Why 1 Cause
5 Involved Person

Why 2 Cause

Why 3 Cause

Why 4 Cause

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