J&R Near Miss

• Audit Title

• DATE & TIME :

  Date
• STREET ADDRESS
  Address

• REPORTED BY:

• PROJECT NAME / JOB NUMBER:

INJURIES

• WAS THERE ANY INJURIES?

  YES

  NO

• SELECT AREA OF INJURY?

  Select 1) Head 2) Neck 3) Chest 4) Adbomen 5) Shoulder 6) Arms 7) Elbow 8) Forearm 9) Wrist 10) Hand 11) Hip 12) Thigh 13) Knee 14) Calf 15) Top of foot 16) Foot 17) Nape 18) Lumber region 19) Buttock

  • 1) Head
  • 2) Neck
  • 3) Chest
  • 4) Adbomen
  • 5) Shoulder
  • 6) Arms
  • 7) Elbow
  • 8) Forearm
  • 9) Wrist
  • 10) Hand
  • 11) Hip
  • 12) Thigh
  • 13) Knee
  • 14) Calf
  • 15) Top of foot
  • 16) Foot
  • 17) Nape
  • 18) Lumber region
  • 19) Buttock

• DETAILS OF INJURY?

PROPERTY / PLANT / CABLE DAMAGE

• WAS THERE ANY DAMAGE TO PROPERTY?

  YES

  NO

• SELECT DAMAGE

  Select Comms Gas Power Water Private Property Environmental Vehicle Plant / Machinery Drainage

  • Comms
  • Gas
  • Power
  • Water
  • Private Property
  • Environmental
  • Vehicle
  • Plant / Machinery
  • Drainage

• If Company property, please enter JR Number

NEAR MISS

• DESCRIBE WHAT HAPPENED:

• WHAT WOULD YOU DO TO STOP THIS FROM HAPPENING AGAIN:

• PHOTOGRAPHS

  Media

PROJECT MANAGER TO REVIEW

• WHAT WAS THE CAUSE?

  Select Inadequate guarding Inadequate lighting Inadequate/lack of training Inadequate/lack of work procedures Lack of supervision Exposure to chemicals/hazardous substances Exposure to sound/noise Congested Work areas/poor housekeeping Faulty equipment/materials Lack of PPE Fire/Explosion No Risk Assessments No safety equipment Plans not on site or incorrect Ducts not where plans indicate No spotter Incorrect markout Lack of concentration Assumed cable/duct was deeper/shallower

  • Inadequate guarding
  • Inadequate lighting
  • Inadequate/lack of training
  • Inadequate/lack of work procedures
  • Lack of supervision
  • Exposure to chemicals/hazardous substances
  • Exposure to sound/noise
  • Congested Work areas/poor housekeeping
  • Faulty equipment/materials
  • Lack of PPE
  • Fire/Explosion
  • No Risk Assessments
  • No safety equipment
  • Plans not on site or incorrect
  • Ducts not where plans indicate
  • No spotter
  • Incorrect markout
  • Lack of concentration
  • Assumed cable/duct was deeper/shallower

• OTHER CAUSE NOT LISTED

• FURTHER ACTION / RECOMMENDATIONS

  Further training required

  Discuss at next toolbox meeting

  Send for repair

  Have meeting with individual

• COMMENTS:

H&S COMMITEE REVIEWED:

• COMMENTS:

• SIGNATURE:

  Sign

• DATE COMPLETED :

  Date

MANAGEMENT REVIEW

• Comments of findings if escalated to management:

• Signature

  Sign