Near Miss Investigation Report

• Document No.

• Audit Title (NM-initials of reporter-mm-dd-yy)

• Date and Time Near Miss occurred

  Date

• Area / Location of Near Miss

  Select press feeder jogging block out finish cut PCM packing banding sheeter other

  • press
  • feeder
  • jogging
  • block out
  • finish cut
  • PCM
  • packing
  • banding
  • sheeter
  • other

PERSONAL INFORMATION (injured employee)

• Name of associate(s) involved

• Enter date and time of incident

  Date

• Picture of near miss report submitted to Safety Team

  Media

Manager / Safety Team Investigation

• Employment Category

  Full time

  Part time

  Contractor

  Visitor

• Length of employment

  less than 1 month

  > 1 to 6 months

  > 6 months to 1 year

  1 year to 5 years

  > 5 years

• Time in occupation at time of incident

  less than 1 month

  > 1 to 6 months

  > 6 months to 1 year

  1 year to 5 years

  > 5 years

• Type of operation

  Select abrasion laceration trauma slip trip fall contusion

  • abrasion
  • laceration
  • trauma
  • slip
  • trip
  • fall
  • contusion

• Was this operation a regular part of employees job?

  Yes

  No

  N/A

• Type of possible injury or accident

  Select abrasion laceration trauma slip trip fall contusion

  • abrasion
  • laceration
  • trauma
  • slip
  • trip
  • fall
  • contusion

ACCIDENT / INCIDENT SUMMARY

Accident Sequence - describe in reverse order the occurrence of events preceding the injury

• Injury Event / Accident Event

• Describe the preceding events that led up to the injury or accident

Preceding Events

• Add media

  Media

• Was PPE required for this task?

  Yes

  No

  N/A

• What PPE was required and in use at time of incident

PPE REQUIRED

• Provided?

  Yes

  No

  N/A

• Trained on proper use?

  Yes

  No

  N/A

• Proper use of PPE?

  Yes

  No

  N/A

• PPE use enforced by manager and supervisor?

  Yes

  No

  N/A

• Was equipment adequately guarded? If no describe deficiency

  Yes

  No

  N/A

• Has employee received training prior to job assignment?

  Yes

  No

  N/A

• Was training adequate?

  Yes

  No

  N/A

• Were any safety mechanisms by-passed?

  Yes

  No

  N/A

• Was lockout necessary?

  Yes

  No

  N/A

• Was employee trained?

  Yes

  No

  N/A

• Was training adequate?

  Yes

  No

  N/A

• Was lock provided?

  Yes

  No

  N/A

• Was written procedure required?

  Yes

  No

  N/A

• Was procedure provided to follow?

  Yes

  No

  N/A

QUESTIONNAIRE

• After your involvement with this incident, is there any insight you could share or preventative actions you would recommend?

CONCLUSION / ROOT CUASE

• Enter conclusions

• Likely hood of injury (0-low. 5-high)

• Severity of injury? (0-minor 5-fatal)

• Overall Risk Assessment (1 - low : 10 - very high)

CORRECTIVE ACTIONS REQUIRED

• Enter all corrective/preventative actions that will be implemented

PICTURES & DRAWINGS

• Add media

  Media

• Add drawing

  Drawing

SIGN and DATE

• Name / Signature of Employee

  Sign

• Name / Signature of Investigator

  Sign

• Name / Signature of Department Manager

  Sign

• Name / Signature of Safety Team Lead

  Sign