Information
-
Site conducted
-
Incident Report No.
-
Conducted on
-
Employee Name:
-
Instructions:
1. Required to be completed when you experience a Safety Near Miss in the workplace
2. To be completed in full and emailed to supervisor and the Safety Director -
Date & Time of Near Miss:
-
Location of Near Miss. If customer site, please provide address
-
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
-
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?
-
Photo/s that can help explain the what, where, why, or the possible injury:
-
Name and Signature (optional)
