Type of hazard Near Miss Workplace Hazard Hazardous Work Practice Time and date of incidentTime : Hours Minutes AM PM Date DD slash MM slash YYYY Where is the hazard located?What is the hazard?What is the risk (refer Risk Assessment Matrix)?Who is at risk?What action was taken?Further RecommendationsReported by* Referred to* (Workplace Manager or Delegate)Corrective Action Completed Incomplete Interim/short term control(s) requiredLong term control(s) requiredWorkplace Manager's Name:* NameThis field is for validation purposes and should be left unchanged.
