NEAR - MISS NOTIFICATION FORMAT

No.
(Please write as YYYY/NNNN, to be filled by Investigation lead)
1 Name of Initiator:
2 Department:
3 Date of Near-miss observation: Time:
4 Place Where Near-miss may occurred:
5 Please describe the Near-miss point:

6 How likely is this to re-occur: Probability? (Of A person or property may be exposed to, in a similar
situation, and that required hazards or system failure may be present or likely. Ex. High: Task occurs on a regular basis
and by numerous individuals. Medium: Task occurs on a regular basis and by few individuals. Low: Tasks occurs
infrequently by few individuals. Also consider such criteria as complexity of system, latent and human factor etc.)
HIGH MEDIUM LOW
7 Potential Severity for Fatality Major Injury Lost Time Accident Minor Injury
Human: (encircle yes/no) YES / NO YES / NO YES / NO YES / NO
8 Potential Severity for High Medium Low
Property/Environment: (Tick one) (Big damage) (Some Damage) (No Damage)
9 Was this due to: Unsafe Act YES / NO Unsafe Condition YES / NO
10 Recommendations by initiator to prevent an occurrence:

11 Final Recommendations by Investigation team:

(Team Members: _____________, _______________, _____________, ____________)

11 Responsible department to rectify the near-miss notification:

12 Action Taken Report (By concerned department)

Action taken confirmed by: ( Dept. HOD concerned ) Date

13 Actions Verified and NM Completed (To be filled) Date

EHS Department
Points no 1 to 10 to be filled up by Initiator and submitted to investigation lead.