Near Miss / Hazard ID – Timbro Forms

Job Number

Definitions

Near Miss – Any event, which under slightly different circumstances, may have resulted in injury or ill health of people, damage or loss of property.

Hazard – Source or situation with a potential for harm in terms of injury, ill health, damage to property, or damage to workplace and environment, or any other definitions as set out by regulations and codes.

Please choose type of Report

Near Miss

Hazard Identification

Observation

Reported By

Date Reported

Check ALL applicable

Unsafe Act

Unsafe Equipment

Unsafe Condition

Unsafe use of Equipment

Description of Near Miss or Hazard:

What was the potential consequence?

Recommendations

Corrective action taken

Corrective action taken by

Date of corrective action

Action Required?

Further Investigation Required

Toolbox Talk Required