ACI - Near Miss / potential Hazard Identification Report

• Date and time of Near Miss or when potential Hazard was discovered by ACI employee or witness:

  Date

• Name of Near Miss or potential Hazard (Summary description of what happened?):

• 1. Within 24 hours the witness or person with knowledge of Near Miss / potential Hazard must complete Section 1.
  2. The employee who completes section 1 must email or print this form and turn into their immediate supervisor.
  3. Supervisor must conduct an incident investigation and complete Section 2.
  4. Upon supervisor's completion of Section 2, the entire form must be sent to the safety coordinator.

Section 1 (Completed by witness or employee involved in Near Miss or who found potential Hazard):

• Description of Near Miss or potential Hazard (who, what, where, when, why and how did Near Miss occur or what is the potential Hazard?)

• Department / Service Line:

• Location of Near Miss event or potential Hazard or equipment number where potential Hazard exists:
  Address

• Check all that apply (attach photos if available):

• Unsafe Condition

• Unsafe Equipment

• Unsafe Use of Equipment

• Unsafe Act/ Behavior

• Employee Name (Optional):

  Sign

Section 2 (Completed by Manager or Supervisor conducting investigation of Near Miss or potential Hazard):

• After the investigation, explain in detail what caused the Near Miss or potential Hazard to exist/occur:

• Review each area below and check all that apply:

• Equipment:

  Select Equipment Failure Improper Equipment or Material used for the job Guard removed from equipment

  • Equipment Failure
  • Improper Equipment or Material used for the job
  • Guard removed from equipment

• Personal Protective Equipment:

  Select Not Worn Not readily available Not adequate for the task PPE failure

  • Not Worn
  • Not readily available
  • Not adequate for the task
  • PPE failure

• Training / Experience:

  Select Lack of Training Failure to follow procedures New task for employee of lack of experience Incomplete Safe Operating Procedure Outdated Safe Operating Procedure

  • Lack of Training
  • Failure to follow procedures
  • New task for employee of lack of experience
  • Incomplete Safe Operating Procedure
  • Outdated Safe Operating Procedure

• Work Area:

  Select Work Area set up improperly Ergonomic Factors Sanitary and housekeeping issues Lack of cord management Ice or wet conditions Loose handrails Chipped tile or loose carpet/rug 3 foot clearance in front of electrical panel Lack of Safety Data Sheets

  • Work Area set up improperly
  • Ergonomic Factors
  • Sanitary and housekeeping issues
  • Lack of cord management
  • Ice or wet conditions
  • Loose handrails
  • Chipped tile or loose carpet/rug
  • 3 foot clearance in front of electrical panel
  • Lack of Safety Data Sheets

• Employee(s):

  Select Employee Fatigue Unbalanced or poor position or motion Not paying attention Improper footwear for conditions Going too fast Taking short cuts Not aware of surroundings Lack of policy / procedure Poor housekeeping practices Improper behavior and attitude Disregard for safety rules Unsafe Practice

  • Employee Fatigue
  • Unbalanced or poor position or motion
  • Not paying attention
  • Improper footwear for conditions
  • Going too fast
  • Taking short cuts
  • Not aware of surroundings
  • Lack of policy / procedure
  • Poor housekeeping practices
  • Improper behavior and attitude
  • Disregard for safety rules
  • Unsafe Practice

• Environmental Factors:

  Select Clear Rain Snow Sleet Hail Severe Weather Heat

  • Clear
  • Rain
  • Snow
  • Sleet
  • Hail
  • Severe Weather
  • Heat

• Corrective Actions:

  Select Develop / Revise safety policies / procedures and/or update plan Request ergonomic evaluation Require personal protective equipment Remove equipment from use and repair or replace Schedule Preventative Maintenance Retrain employee with proper procedures Require baseline safety training Inform employee to slow down Address attitude & behavior Address employee work practices Maintain housekeeping and sanitary conditions Work Order completed

  • Develop / Revise safety policies / procedures and/or update plan
  • Request ergonomic evaluation
  • Require personal protective equipment
  • Remove equipment from use and repair or replace
  • Schedule Preventative Maintenance
  • Retrain employee with proper procedures
  • Require baseline safety training
  • Inform employee to slow down
  • Address attitude & behavior
  • Address employee work practices
  • Maintain housekeeping and sanitary conditions
  • Work Order completed

• Manager or Supervisor Name:

  Sign