Information
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Employee Name (optional):
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Date & Time of Hazard/ Near Miss:
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Farm:
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Department/ location of Hazard/Near Miss.
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Instructions:
1. Required to be completed when you experience a Safety Hazard/ Near Miss in the workplace
2. To be completed in full and emailed to farm manager or the Health & Safety Advocate. -
Hazard is defined as, "A potential source of harm to a worker"
Near Miss Defined: OSHA and the National Safety Council defines a near miss as an “unplanned event that did not result in injury, illness or damage – but had the potential to do so.” -
Select the report type:
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Select Unsafe Act and/or Unsafe Condition:
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Select the severity of the risk
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Include a description of Hazard and/or Near – Miss Incident and explain Unsafe Condition and/or Unsafe Acts:
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Identify root causes:
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Corrective Action(s) Taken: Note: Follow hierarchy of controls based on level of risk
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Photo/s that can help explain the what, where, why, or the possible injury:
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Was the hazard controlled?
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Farm manager to complete if additional resources are required to control the hazard
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Name and Signature
