Envirotrol - Near Miss Report

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

GENERAL INFORMATION

• SPECIFIC LOCATION OF OBSERVATION (I.E. 2ND FLOOR, ROOFTOP, LOADING DOCK, ETC.)

• DATE AND TIME OF INCIDENT OR HAZARD DISCOVERY

  Date

• PLEASE SELECT YOUR DEPARTMENT

  Controls Installation

  Controls Service

  Mechanical Service

  Office

  Sales

• PLEASE SELECT CAUSE OF OBSERVATION

  Unsafe Act

  Unsafe Condition

OBSERVATION CLASSIFICATION

• PLEASE SELECT THE MOST APPROPRIATE NEAR MISS CATEGORY

  Select Auto Cranes Compressed Gas Cylinders Electrical Excavations Fall Protection Forklit/Lull Hand/Power Tools Hazardous Materials Hot Work/Welding Housekeeping Hygiene Ladders Manual Material Handling Pressure Testing PPE Scissor/Boom Lift Tripping Hazards Weather

  • Auto
  • Cranes
  • Compressed Gas Cylinders
  • Electrical
  • Excavations
  • Fall Protection
  • Forklit/Lull
  • Hand/Power Tools
  • Hazardous Materials
  • Hot Work/Welding
  • Housekeeping
  • Hygiene
  • Ladders
  • Manual Material Handling
  • Pressure Testing
  • PPE
  • Scissor/Boom Lift
  • Tripping Hazards
  • Weather

• PLEASE SELECT THE MOST LIKELY POTENTIAL INJURY BY TYPE

  Select Burn Contusion Cut/Puncture/Laceration Electric Shock Eye Irritation Fracture/Broken Bone Hearing Loss Heat Exhaustion Illness Insect/Animal Skin Irritation Sprain/Strain

  • Burn
  • Contusion
  • Cut/Puncture/Laceration
  • Electric Shock
  • Eye Irritation
  • Fracture/Broken Bone
  • Hearing Loss
  • Heat Exhaustion
  • Illness
  • Insect/Animal
  • Skin Irritation
  • Sprain/Strain

• PLEASE SELECT THE MOST LIKELY INJURY BY CAUSE

  Select Burn Caught in Between Electric Shock HAZMAT Exposure Heat Exhaustion Insect/Animal Material Handling Noise Exposure Object in eye Slip/Trip/Fall Spreading Germs Struck by

  • Burn
  • Caught in Between
  • Electric Shock
  • HAZMAT Exposure
  • Heat Exhaustion
  • Insect/Animal
  • Material Handling
  • Noise Exposure
  • Object in eye
  • Slip/Trip/Fall
  • Spreading Germs
  • Struck by

DESCRIPTION OF OBSERVATION

• PLEASE DESCRIBE THE INCIDENT OR HAZARD

• PLEASE DESCRIBE THE ROOT CAUSE OF OBSERVATION

• PLEASE ATTACH PICTURE OF AREA WHERE INCIDENT OCCURRED OR WHERE HAZARD EXISTS

  Media

• WAS CORRECTIVE ACTION TAKEN?

  YES

  NO

• PLEASE DESCRIBE CORRECTIVE ACTION TAKEN

• PLEASE ATTACH PICTURE OF AREA AFTER CORRECTIONS

  Media

EMPLOYEE SIGNATURE

• PLEASE SIGN BELOW

  Sign