NEAR MISS NOTICE

• Conducted on

  Date

• Prepared by

• Location
  Address

• A near miss is an incident which potentially could have caused Injury or Occupational disease and/or damage (loss) to people, assets, the environment or reputation, but which did not. Overexposure to hazardous chemicals, noise and other health hazards should be considered as near misses when the exposure did not result in an identified illness

• Date of Near Miss:

  Date

• Time of Near Miss: AM PM

  Date

General Information

• Where did the near miss occur? Office, Plant, Terminal, Jobsite, Offsite/Roadway/Highway (work related activities only)

• Name of facility the near miss is associated with or location. i.e. Pennsuco Cement, Roanoke Cement, etc

• Did the near miss occur to a 3rd party such as a contractor, etc.?

  Yes

  NO

• Were there any environmental factors that may have contributed to the near miss?

  Yes

  NO

• How did the near miss occur?

• What was the lesson(s) learned?

• Please provide the immediate corrective action taken to avoid recurrence of this incident

• Do you have a Safety suggestion or recommendation for the prevention of this type of incident?

• What date was corrective action completed?

  Date

• Optional Information (name will remain confidential.) Employee Name:

• SEND FORM TO: Bill Griffin for Florida:

• Melissa McDaniel for Mid-Atlantic: Ɩ Fax: (540) 966-2115