This form is to be completed by the BCC Forman / Supervisor for INFORMATION ONLY or NEAR-MISS Events.
If and INJURY or FIRST-AID was administered, please complete the appropriate form HERE.

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Foreman Report: Info Only / Near-Miss

BCC Foreman / Supervisor Details

Foreman / Supervisor FIRST Name

Foreman / Supervisor LAST Name

Email Address

Phone

Event Details

Date of Event*

Select Date ×

Time of Event*

Example: 9:05 AM

Date Reported*

Select Date ×

Location:*

(City, State, Building, etc)

Description of the Event / Near-Miss*

(Include: tools or equipment in use, task being performed, etc.)

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Describe in detail the Event / Near-Miss, including who was inloved.*

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Party Involved #1*

Name, Email, Phone, Occupation

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Party Involved #2

Name, Email, Phone, Occupation

Write Here

Party Involved #3

Name, Email, Phone, Occupation

Write Here

Witness Information

Name, Email, Phone + Any relevant details

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Safety Suggestions*

Your recommendations to prevent this from occurring again? (Please be specific)

Write Here

Information Only / Near-Miss

BCC Foreman / Supervisor Details

Event Details

BCC Foreman / Supervisor Signature

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