Title Page
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Site conducted
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Classification
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Conducted on
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Prepared by
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Location
Report
Part A. General Information
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Date and Time of Incident
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Date and Time of First Report
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Business Area (select one)
- Honeycomb
- Roller Shades
- Shutters
- Maintenance
- Warehouse
- Parts/Repairs
- Engineering
- Office
- Other
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Specify Other Business Area
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Product Type (select if applicable)
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Department (Assembly/Rail/etc.)
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Exact Location (Equip SAP #, Table #, Room, Pole #, etc.)
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Category
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Was work stopped due to a hazard?
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Please provide details
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Was anyone exposed to body fluids?
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Who?
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Accident Type (select all that apply)
- Bodily Reaction
- Exposure to or contact with
- Fall from height/same level
- Fire/Explosion
- Harmful substance
- Illness
- Material handling (e.g. lifting, carrying)
- Overexertion
- Repetitive motion
- Slip
- Struck by/Against
- Transportation accident
- Trapped / caught by
- Trip
- Use of hand tool
- Workplace violence
- Other
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Please specify Other Accident Type
Part B. Individual Involved
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First Name
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Last Name
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Employee ID Number
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Temp. Employee
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Job Title
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Shift
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Supervisor
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Time Employee Began Shift
Part C. Incident Details
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Describe the incident fully. Include the events leading up to the incident, any equipment or substances involved, any injuries or damage sustained, and any other important details regarding the incident.
Part D. Injury/Illness Details If the incident was a near miss (no personal injury sustained), skip this section.
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Nature of Illness/Injury: (select all that apply)
- Amputation
- Bite
- Broken Bone
- Bruise
- Burn
- Chemical Contamination
- Concussion
- Cut (Minor)
- Cut (Stitches or Sutures)
- Dislocation
- Electric Shock
- Fatality
- Foreign Body Penetrating
- Hearing Loss
- Inflammation
- Irritation
- Loss of Consciousness
- Musculoskeletal Disorder
- Poisoning
- Respiratory Condition
- Skin Disorder
- Smoke or Fume Inhalation
- Sprain
- Strain
- Upper Limb Disorder (Tendonitis, CTS)
- Other
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Please specify Other Nature of Illness/Injury
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Body Part (select all that apply)
- Back- Lower
- Back- Upper
- Chest
- Ear - Left
- Ear - Right
- Eye - Left
- Eye - Right
- Face
- Groin
- Internal
- Neck
- Nose
- Ribs
- Torso
- Head
- Shoulder - Left
- Shoulder - Right
- Upper Arm - Left
- Upper Arm - Right
- Elbow - Left
- Elbow - Right
- Lower Arm - Left
- Lower Arm - Right
- Wrist - Left
- Wrist - Right
- Hand - Left
- Hand - Right
- Finger - 1st
- Finger - 2nd
- Finger - 3rd
- Finger - 4th
- Finger - 5th
- Buttocks/Pelvis
- Upper Leg - Left
- Upper Leg - Right
- Knee - Left
- Knee - Right
- Lower Leg - Left
- Lower Leg - Right
- Ankle - Left
- Ankle - Right
- Foot - Left
- Foot - Right
- Toe - 1st
- Toe - 2nd
- Toe - 3rd
- Toe - 4th
- Toe - 5th
- Other
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Please specify Other Body Part
Part E: Causal Factors and Associated Activities: (select all that apply) Contributed to the incident happening.
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Process
- Inadequate policy/procedure
- Inadequate training/education/instruction/JSA
- New task for employee/lack of experience
- Rotation schedule
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Equipment
- Improper equipment or material used for job
- Guard removed from equipment
- Emergency stop/release failure/malfunction
- PPE not effective
- Equipment failure
- Inadequate guard
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Environment/Work Area
- Physical space and layout
- Ergonomic factors
- Unsafe working surfaces
- Housekeeping issues
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People
- Not aware of surroundings
- Taking shortcuts
- Eyes on task
- Horseplay/Carelessness
- Not following procedures
- Distractions/Interruptions
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Please list any others:
Part F: Details of First Aid Measures, if applicable (Band-Aid, wound care, hydrocortisone cream, ice, etc.)
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Part G: Recommendations to Prevent Recurrence: If an engineer is the Person Responsible, include the Engineering Manager and Engineer in Near Miss email.
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Tap "+"
Recommendation
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What measures are being taken to prevent this incident from recurring?
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Person responsible for action
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Scheduled completion date
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CI Card Submitted?
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CI Card Number
Part H: Review
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Supervisors: Please send this document to your Operations Manager and the Safety Department if there was an injury.
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Completed By: (Signature)
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Notes (EHS Internal Use Only):
