Near miss/Hazard Report Form ID #

Name: Date: Time:

Position: Telephone No.:

Location of Hazard:
Unit:
Please give a full description of the nature of the hazard and a sketch if
appropriate.

Whether stop work Authority Used Yes No

Recommendation/ Suggestion

Official Use

Corrective Action taken to eliminate the Hazard

Corrective Action taken By: Signature Date:

Verified By: Signature Date:

Checked By: Approved By: Date: