K Near Miss Form

• Company Name:

  K

• Contractor Involved in the near miss

  k

• Date & Time Of The Near Miss Reported:

  Date

• Weather Condition

  Clear/sunny

  Cloudy

  Rain

  Snow

• Temperature

• Wind Condition at the time of near miss

  0-10 mph

  10-20 mph

  20-30 mph

  30-40 mph

  40-50 mph

• Prepared By:

  k

• Position in the Company:

  Safety Director

  Foreman

  Superintendent

• Name of affected employee:

• Was anyone injured?

  Yes

  No

  N/A

• If so name and what Body part or parts?

• Date and time when the near miss Actually occurred:

  Date
• Site/location of the near miss:
  Address

• Category the near-miss most relates to.

  Select Fall From Trip / Fall on same level Electric shock Caught between Falling object Other Equipment/machine

  • Fall From
  • Trip / Fall on same level
  • Electric shock
  • Caught between
  • Falling object
  • Other
  • Equipment/machine

• Description of the near miss.

• Where exactly in the site/location did the near miss occur? (the specific area, room, floor, or building)

• What hazard/s triggered the near miss?

• To add a photo or image related to the near miss, click the "Photo" icon at the bottom right:

  Yes

  No

  N/A

• Where there any employees in the specific area, room, floor, or building at the time of the near miss.

  Yes

  No

  N/A

• If so trade and names.

• Any Property Damage?

  Yes

  No

  N/A

• If so What was Damaged.

Identifying Root Causes

• What caused or allowed the near miss to happen?

• Factors that contributed to the near miss were found in which areas? Select all that apply.

  Select Equipment Procedures Training Environment Tools

  • Equipment
  • Procedures
  • Training
  • Environment
  • Tools

• Was a machine or safety device in use during the near miss?

  Yes

  No

  N/A

• If so what machinery was involved?

• Were safety procedures being followed?

  Yes

  No

  N/A

Severity Level

• Level of severity

  Extreme

  Major

  Moderate

  Minor

• Possible out come

Workers Statement

• In own words.

Recommended Corrective Action

• Is there a corrective action plan moving forward?

  Yes

  No

  N/A

• If so What is it?

Follow-Up

• Will there be any follow up?

  Yes

  No

  N/A

• Lesson learned

• Name and Signature:

  Sign