Title Page
-
Inspection Number
-
Dated
-
Inspector Name
HSE
- Observation or Near Miss
-
What has been seen?
-
Observation Location
-
Observation Related to
-
Hazard Location
-
Type of Near Miss
-
Hazard Type
-
Physical Hazard Type
- Electrical (Shock/burn)
- Entanglement
- Crushing
- Cutting, Stabbing & Puncturing
- Shearing
- Friction
- Striking
- Slipping, Tripping & Falling
- High Temperature or Fire
- Temperature (Thermal Comfort)
- Entrapment
- Hazardous/Stored Energy
- Radiations (ionizing)
- Radiations (non-ionizing)
- Revolving entities
- Rotating entities
- Moving entities (on floor)
- Moving entities (overhead)
- Falling objects
- Ejection (flying pieces or parts)
- Improper storing/stacking (falling materials)
- Improper floor or surface (tripping/slipping)
- High pressure points (e.g. High Pressure Fluid)
- High temperature points/surfaces
- Work at heights (falls)
- Confined Space (toxic gases/suffocation)
- Obstructions/Collisions/Contacts/Impacts
- Vibration
- Natural Hazard (lightning, flood, earthquake)
- Violence or robbery
- Over turning
-
Minor injury/Illness
-
Lost Time Injury / Illness
-
Permanent Disability
-
Fatality
-
Rarly
-
Unlikely ( could occur at some time, but less possible )
-
Possible (might occur at some time)
-
Likely (will probably occur in most circumstances)
-
Almost Certain (Expected to occur in most circumstances)
-
Certain (Expected to occur in all circumstances)
-
Chemical Hazard Type
- Explosion
- Fire (electric/chemical/fuel)
- Combustible materials
- Flammable materials
- Oxidizing materials
- Corrosive/irritating materials
- Dust/Particles
- Fumes/Vapors
- Toxic Gases
- Mist/Fog
- Frost bite
-
Its Severity
-
Its Probability
- Rare (May occur only in exceptional circumstances)
- Unlikely (could occur at some time, but less possible)
- Possible (might occur at some time)
- Likely (will probably occur in most circumstances)
- Almost Certain (Expected to occur in most circumstances)
- Certain (Expected to occur in all circumstances)
-
Its Probability
- Rare (May occur only in exceptional circumstances)
- Unlikely (could occur at some time, but less possible)
- Possible (might occur at some time)
- Likely (will probably occur in most circumstances)
- Almost Certain (Expected to occur in most circumstances)
- Certain (Expected to occur in all circumstances)
-
Its Probability
- Rare (May occur only in exceptional circumstances)
- Unlikely (could occur at some time, but less possible)
- Possible (might occur at some time)
- Likely (will probably occur in most circumstances)
- Almost Certain (Expected to occur in most circumstances)
- Certain (Expected to occur in all circumstances)
-
Its Probability
- Rare (May occur only in exceptional circumstances)
- Unlikely (could occur at some time, but less possible)
- Possible (might occur at some time)
- Likely (will probably occur in most circumstances)
- Almost Certain (Expected to occur in most circumstances)
- Certain (Expected to occur in all circumstances)
-
Biological Hazard Type
- Animal/Insect bite or sting
- Infections (blood/needles)
- Bacteria/Viruses
- Unhygienic conditions
- Food Contamination
- Clinical Waste
- Contagious diseases
- Algae or diseased plants
-
Its Severity
-
Its Probability
- Rare (May occur only in exceptional circumstances)
- Unlikely (could occur at some time, but less possible)
- Possible (might occur at some time)
- Likely (will probably occur in most circumstances)
- Almost Certain (Expected to occur in most circumstances)
- Certain (Expected to occur in all circumstances)
-
Its Probability
- Rare (May occur only in exceptional circumstances)
- Unlikely (could occur at some time, but less possible)
- Possible (might occur at some time)
- Likely (will probably occur in most circumstances)
- Almost Certain (Expected to occur in most circumstances)
- Certain (Expected to occur in all circumstances)
-
Its Probability
- Rare (May occur only in exceptional circumstances)
- Unlikely (could occur at some time, but less possible)
- Possible (might occur at some time)
- Likely (will probably occur in most circumstances)
- Almost Certain (Expected to occur in most circumstances)
- Certain (Expected to occur in all circumstances)
-
Its Probability
- Rare (May occur only in exceptional circumstances)
- Unlikely (could occur at some time, but less possible)
- Possible (might occur at some time)
- Likely (will probably occur in most circumstances)
- Almost Certain (Expected to occur in most circumstances)
- Certain (Expected to occur in all circumstances)
-
Ergonomic Hazard Type
- Improper Light (Glare/Poor light)
- Improper Work Temperature/Humidity
- Improper Ventilation
- Manual lifting, handling or shifting
- Repetitive movements
- Poor Posture
- Poor workplace design/layout
- Congested workplace
- Long sittings/duration of work
- Improper work rest cycles
- Stressful tasks
- Noise
-
Its Severity
-
Its Probability
- Rare (May occur only in exceptional circumstances)
- Unlikely (could occur at some time, but less possible)
- Possible (might occur at some time)
- Likely (will probably occur in most circumstances)
- Almost Certain (Expected to occur in most circumstances)
- Certain (Expected to occur in all circumstances)
-
Its Probability
- Rare (May occur only in exceptional circumstances)
- Unlikely (could occur at some time, but less possible)
- Possible (might occur at some time)
- Likely (will probably occur in most circumstances)
- Almost Certain (Expected to occur in most circumstances)
- Certain (Expected to occur in all circumstances)
-
Its Probability
- Rare (May occur only in exceptional circumstances)
- Unlikely (could occur at some time, but less possible)
- Possible (might occur at some time)
- Likely (will probably occur in most circumstances)
- Almost Certain (Expected to occur in most circumstances)
- Certain (Expected to occur in all circumstances)
-
Its Probability
- Rare (May occur only in exceptional circumstances)
- Unlikely (could occur at some time, but less possible)
- Possible (might occur at some time)
- Likely (will probably occur in most circumstances)
- Almost Certain (Expected to occur in most circumstances)
- Certain (Expected to occur in all circumstances)
-
Its Severity
-
Its Probability
- Rare (May occur only in exceptional circumstances)
- Unlikely (could occur at some time, but less possible)
- Possible (might occur at some time)
- Likely (will probably occur in most circumstances)
- Almost Certain (Expected to occur in most circumstances)
- Certain (Expected to occur in all circumstances)
-
Its Probability
- Rare (May occur only in exceptional circumstances)
- Unlikely (could occur at some time, but less possible)
- Possible (might occur at some time)
- Likely (will probably occur in most circumstances)
- Almost Certain (Expected to occur in most circumstances)
- Certain (Expected to occur in all circumstances)
-
Its Probability
- Rare (May occur only in exceptional circumstances)
- Unlikely (could occur at some time, but less possible)
- Possible (might occur at some time)
- Likely (will probably occur in most circumstances)
- Almost Certain (Expected to occur in most circumstances)
- Certain (Expected to occur in all circumstances)
-
Its Probability
- Rare (May occur only in exceptional circumstances)
- Unlikely (could occur at some time, but less possible)
- Possible (might occur at some time)
- Likely (will probably occur in most circumstances)
- Almost Certain (Expected to occur in most circumstances)
- Certain (Expected to occur in all circumstances)
