Hazard Near Miss

• Site

  Select

• Date

  Date

• Centers are required to conduct and document daily/weekly/monthly inspections. Results of the inspection are recorded below. In the event a deficiency is identified but cannot be corrected, the Safety Officer, Dorm Coordinator, Department Manager or Building Manager will submit a maintenance work order. Completed checklist must be returned to the Center Safety Officer, [CSO]. Not all areas are inspected; however, this report shows the findings of those areas inspected.

• Areas of the inspection are conducted at random. Not all items will be inspected. As such, not all deficiencies or good practices will be observed or noted. Please ensure you are always inspecting your areas. Please use this report as a guidance on how to conduct your own inspections within your area. Please also share this report with your staff within your areas to improve on Safety within your area.

• Please share with your staff to make improvements to safety related issues.

• Document Number

• If deficiencies were found, they must be corrected by the date provided. Afterwards, you will need to notify the Safety Officer by no later than the date provided by email & accompanying photographs. If there were no deficiencies, then please just share the findings with your staff.

• Prepared by

• If there were any deficiencies found, you will need to notify the Center Safety Officer once they are corrected, so a follow-up inspection can be completed.

• Items inspected are at random. As such, the findings will be listed below.

Hazard/Near Miss Finding

• Hazard/Near Miss discovered by

  Select Staff Student Other Center Safety Officer

  • Staff
  • Student
  • Other
  • Center Safety Officer

• Hazard/Near Miss

  Select HAZARD NEAR MISS MAINTENANCE ISSUE IT Dept. Issue OTHER Safe Practice Deficiency Finding

  • HAZARD
  • NEAR MISS
  • MAINTENANCE ISSUE
  • IT Dept. Issue
  • OTHER
  • Safe Practice
  • Deficiency Finding

• Please complete by and notify the Safety Officer by email once the Hazard/Near Miss has been corrected.

  Date

• Please complete by and notify the Safety Officer by email once the Hazard/Near Miss has been corrected.

  Date

• Please complete by and notify the Safety Officer by email once the Hazard/Near Miss has been corrected.

  Date

• Precise location

• Notification will be sent to

  Select CENTER DIRECTOR DEPUTY CENTER DIRECTOR Department Manager MAINTANENCE SUPERVISOR IT Dept. SAFETY OFFICER Community Life Coordinator Work Order will be submitted by the CSO Other > Please specify in notes

  • CENTER DIRECTOR
  • DEPUTY CENTER DIRECTOR
  • Department Manager
  • MAINTANENCE SUPERVISOR
  • IT Dept.
  • SAFETY OFFICER
  • Community Life Coordinator
  • Work Order will be submitted by the CSO
  • Other > Please specify in notes

• Who is the responsible Supervisor or Building Manager

• Issue has been corrected?

  Select Compliant Non-Compliant N/A Not Inspected Follow-Up Needed. Items Corrected.

  • Compliant
  • Non-Compliant
  • N/A
  • Not Inspected
  • Follow-Up Needed.
  • Items Corrected.

• Was Work Order # entered?

Eligibility

• Is this Hazard/Near Miss submitted eligible for the Cash Reward?

  Select Yes No N/A Rejected, Please see notes below

  • Yes
  • No
  • N/A
  • Rejected, Please see notes below

• Name of Staff or Student

• Staff or Student ID #

Is there any additional information to this Hazard/Near Miss?

• undefined

Light/Sound/Narcan Boxes

Digital Sound Level Meter OSHA Reg. 1910.95

• dbA

Light Meter Reading OSHA Reg. 1915.82

• Lumens (Lux)

• Naloxone container in area still present and in good working codition?

  Yes

  No

  N/A

• Does the Naloxone need to be refilled? There should be 2 present

  Yes

  No

  N/A

• How many are needed?