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CONSTRUCTION NEAR MISS REPORT
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REPORT CONTROL & PROJECT DETAILS
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Report numberRevision number
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StatusConfidentiality
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Project nameProject number
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Event dateEvent time
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Exact locationReported by
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Reported toReport date
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EVENT CLASSIFICATION
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Near miss categoryEvent type
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Actual consequence
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Potential severityHigh potential
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Work stoppagePublic exposure
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PEOPLE & WITNESSES
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Primary person involved
Company / role
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Witness summary
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EVENT DESCRIPTION & POTENTIAL CONSEQUENCES
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Event titleEvent description
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Sequence of events
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Potential consequences
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IMMEDIATE ACTIONS & WORK RESUME
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Immediate action description
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Work stoppedArea secured
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Temporary control installed
Work-resume approval required
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Work-resume approval
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REVIEW & CONTRIBUTING FACTORS
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Review lead
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Review completion date
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Contributing factors
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CORRECTIVE ACTIONS & LESSONS LEARNED
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Immediate corrective actions
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Effectiveness review
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REFERENCES, APPROVAL & CLOSURE
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Supporting references
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Supervisor reviewer
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Management reviewer
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Approval dateClosure date
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Closure notes
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