C&W Near Miss Reporting Form

NEAR MISS REPORTING FORM

• Client / Site

• Add location
  Address

• Conducted on

  Date

• Task

• Personnel

• Prepared By

• Supervisor

• Document No.

Event Location

• Location (UTrac 4-digit code):

• Client:

• Floor:

• Room/Space:

• Observer:

• Event Date and Time:

  Date

Consequence Category:

• Consequence Category

  Select Safety Property Environmental Quality Equipment Other

  • Safety
  • Property
  • Environmental
  • Quality
  • Equipment
  • Other

• If Other, please specify:

Event / Condition Description:

Possible Results / Impacts / Injuries if Not Fixed:

Possible Causes of Event or Condition:

Suggestions on What to Do About Situation:

Action Items:

• Description:

• By When

  Date

• Description

• By When

  Date

• Description

• By When

  Date

• Description

• By When

  Date

Employee Review:

• Department

• Led By

• Date

  Date

• Supervisor / Manager

• Date

  Date

Near Miss Form Quick Reporting Instructions

• Part “A” – Observer
  (The Observer would be the person who noticed the Near Miss situation and is reporting it)
  
  NOTE: If the situation is urgent, where there is an immediate risk of someone being seriously hurt, STOP AREA OPERATIONS, and NOTIFY YOUR SUPERVISOR IMMEDIATELY!
  
  1. Event Location: Enter as much detail as you can about the event and where it happened or might happen
  2. Consequence Category: Check the box or boxes that you think the situation best fits in. For example, a potential chemical spill might be Environmental, while a broken hand rail would be a Safety item.
  3. Event Condition / Description: In your own words, how would you describe the condition? Use as much detail as possible.
  4. Possible Results / Impacts / Injuries If not Fixed: What possible things might happen if the situation is not fixed? Be realistic! Think of the most immediate impact of the situation.
  5. Possible causes: How did this happen? Write in what you think led to this situation occurring
  6. Suggestions about what to do: Write in any ideas you have that you think would prevent the situation from happening again
  7. Take the completed form to your Supervisor
  
  Part “B”: Supervisor Instructions:
  
  1. Get together with the employee: Together, you should both review the Near Miss and draft some Action Items.
  2. Get together with your reports: In a group forum, talk about the Near Miss and the possible Action Items you’ve come up with to solve it
  3. Complete Part “B” of the form: Write in the Action Items, responsible person, and due dates. You and the Observer then sign the form.
  4. Turn it in to EHS: The Regional EHS Management will enter the Action Items into a database, and track them for you.
  5. Keep your people informed: Get together at periodic intervals to update your group as to status of Action Items.