Near Miss Form

SAGA Near Miss Form
Date of the incident*

DayMonthYear
To be completed in cases where an incident has occurred but no injuries are reported. All near miss forms to be completed within seven days.
Details of the person reporting
Surname*
Forename*
Job title*
Site*
Department / Section*
Details of Incident (Describe what happened)*
Exact location of the incident*
Who was nearly injured?*
What plant / equipment was damaged (If any)?*
In your opinion, what is the most serious injury or damage that might have occured?*
Picture 1 (Optional)

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Picture 2 (Optional)

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Picture 3 (Optional)

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Picture 4 (Optional)

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Picture 5 (Optional)

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E-mail*
Date*

DayMonthYear
Should be Empty:

SAGA Near Miss Form