1. Required to be completed when you experience a Safety Near Miss in the workplace
2. To be completed in full and emailed to direct manager or the Health & Safety Manager.
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.”
- Fall from height
- Trip / Fall on same level
- Fall from equipment
- Hazardous Manual Handling
- Electric Shock
- Caught between/underneath
- Hazardous Substance
- Falling object
Describe how the Near Miss occurred (include the body part and type of pain):
Describe what lead up to and caused the Near Miss. Identify root causes:
What was learned and changed due to the Near Miss?