MCC, INC. - NEAR MISS REPORT

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• This near miss report is a tool used to identify hazardous situations we encounter while on the job. This report shall not be utilized for discipline, nor should the person reporting, be held liable for the unsafe condition

LOCATION OF NEAR MISS

• Add location
  Address

• Select date

  Date

DIVISION

• CONCRETE

• AGG

• CONST

• MAINT.

Were MCC employees involved

• YES, LIST BELOW

• NO

WHAT TYPE OF NEAR MISS ARE YOU REPORTING

• Unsafe Act

• Unsafe Equipment

• Unsafe Work Condition

• Unsafe Use of Equipment

DESCRIBE THE NEAR MISS BELOW

• Add media

  Media

LIST CAUSES OF NEAR MISS

ENTER CORRECTIVE ACTION BELOW

REPORTED BY (Print and sign)

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  Sign

MCC DIRECT MANAGER

ENTER ADDITIONAL INFORMATION BELOW

WHO WAS THE NEAR MISS REPORTED TO

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  Sign

• Select date

  Date