PDI Safety
Near Miss Report
Complete by hand and attach photos where indicated.
Date
Time
Jobsite / Project
Job Number
Reported By
Supervisor / Foreman
Crew / Work Activity
Exact Location on Site
Describe the near miss / unsafe condition
What could have happened?
Immediate action taken
Contributing factors
Corrective actions proposed or completed
SIF / PSIF Screening
High-energy hazard involved? ☐ Yes ☐ No ☐ Needs Review
Serious injury/fatality potential? ☐ Yes ☐ No ☐ Needs Review
Direct control in place? ☐ Yes ☐ No ☐ Partial
Follow-up required? ☐ Yes ☐ No
Photo Documentation
Photo 1 — Overall Scene
Attach photo here
Photo 2 — Hazard / Condition
Attach photo here
Photo 3 — Corrective Action
Attach photo here
Photo 4 — Additional View
Attach photo here
Follow-Up Owner
Target Completion Date
Employee / Reporter Signature
Supervisor / Safety Signature