Information
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A near miss is an incident, unsafe act and/or unsafe condition that has not resulted in any personal injury and/or property damage. Unsafe working conditions, unsafe employee work habits, improper use of equipment or use of malfunctioning equipment have the potential to cause work related injuries. It is everyone’s responsibility to report and/or correct these potential accidents/incidents immediately. Please complete this form as a means to report these near miss situations.
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Location
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Conducted on
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If possible take a picture(s) and forward to Kyle Broesder at kbroesder@journeyconstruction.com or text to (605)-838-7716
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Field Superintendent
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Prepared by
Employee Information
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Please check the appropriate contributing factor:
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Description of incident or potential hazard.
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Add any pictures that can help describe the incident or hazard here
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"No Name, No Blame" (below)
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Names are not necessary. You may sign here (Optional)
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Date of Near Miss
Supervisor's Investigation
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Describe Why It Happened:
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Damage/Injury Potential
- Serious
- Non Serious
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Corrective action taken (Remove the hazard, replace, repair, or retrain in the proper procedures for the task)
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Add any pictures that show the corrective action that was taken
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Investigation By:
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Date Completed
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Not completed for the following reason:
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Reviewed By:
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Title:
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Date and Time
