Information
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Site conducted
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Document No.
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Conducted on
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Employee Name (optional):
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Instructions:
1. Required to be completed when you experience an Environmental, Safety or Health related Near Miss in the workplace
2. To be completed in full and emailed to direct manager and the Health & Safety Manager. -
Near Miss Defined
The HSE defines a near miss as an “unplanned event that did not result in injury, illness or damage – but had the potential to do so.” -
Date & Time of Near Miss:
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Location of Near Miss. If customers site, please provide address
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Select the category the near-miss most relates to:
- Fall from height
- Trip / Fall on same level
- Fall from equipment
- Hazardous Manual Handling
- Electric Shock
- Caught between/underneath
- Hazardous Substance
- Falling object
- Other
- Weather conditions
- Covid-19
- Contact with animals
- Trailing cable
- Contact with the public
- Possible physical violence / aggression
- Bullying
- Unstable work equipment (steps, ladder etc)
- Poor housekeeping
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Describe how the Near Miss occurred (include the body part and type of pain that would have been effected):
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Body part?
- Head
- Neck
- Shoulders
- Arms
- Face
- Eyes
- Hands
- Legs
- Knees
- Feet
- Toes
- Fingers
- Breathing in fumes, smoke, dust etc
- No body part effected
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Was the near miss inside or outside?
- Inside
- Outside
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If outside, please describe the weather conditions at the time.
- Raining
- Sunny
- Hot
- Cold
- Windy
- Snowing
- Hail stones
- Storm conditions
- Puddle on floor
- Other
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If inside please describe the conditions.
- Noisy
- Dark
- Flashing lights
- Poor housekeeping
- Traces of waste in work areas
- Other
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Describe the workplace conditions that lead up to and caused the Near Miss. Identify underlying causes:
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List any other persons with you at the time of the near miss situation.
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If on a customers site was the near miss reported to the client representative? if so who
- Yes
- No
- NA
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Who was it reported to?
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What was their response to the issue you reported to them?
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What was learned and changed due to the Near Miss?
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If a photo will help explain the what, where, why, or the injury upload the picture here:
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Are further actions needed for this near miss to make the condition safe?
- Yes
- No
- NA
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If Yes, what do you propose they should be?
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Did the person you reported it to give a corrective action timescale?
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Signature:
