Ovaj obrazac omogućava prijavu Near Miss događaja kako biste unapredili bezbednost na radu. Sadrži polja za ime i potpis, odeljenje (priprema, izrada i pakovanje, magacini, kontrola kvaliteta, inženjering, kancelarije), lokaciju, opis događaja, fotografije, predloge za unapređenje i preduzete akcije. Namenjen je timovima u proizvodnji i srodnim okruženjima radi brze identifikacije opasnosti i pokretanja korektivnih mera.
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