Health & Safety Form v1

NAME

• First Name

• Last Name

When did it happen?

• When did it happen?

  Date

Category of Near miss

• Unsafe Behaviour

• Unsafe Condition

• Unsafe Equipment

• Other

• What was the near miss?

Near Miss Details

• Instructions:
  1. Required to be completed when you experience a Safety Near Miss in the workplace
  2. To be completed in full and emailed to direct manager or the Health & Safety Manager.
  A Near Miss is defined as an unplanned event that did not result in injury, illness or damage – But had the POTENTIAL TO DO SO

• Location of Near Miss
  Address

• Describe details of the "Near Miss"

• What was immediately done about the near miss? Select from drop down. Multiple answers can be chosen

  Select Nothing Reported immediately to shift supervisor / manager Area isolated & Quarantined housekeeping applied to area Machinery tagged out & isolated Reported to maintenance First aid treatment applied other

  • Nothing
  • Reported immediately to shift supervisor / manager
  • Area isolated & Quarantined
  • housekeeping applied to area
  • Machinery tagged out & isolated
  • Reported to maintenance
  • First aid treatment applied
  • other

• Other - Record text

• Has an injury occurred? If yes, an incident report must be completed by the Health & Safety<br>Department.

  Yes

  No

  N/A

• By my signature below I attest that the information I have provided is true and accurate to the best of my knowledge:

  Sign