Information
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Employee Name (optional):
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Please note that by filling out this form, IT IS NOT A PUNITIVE PUNISHMENT and is for learning purposes only. You may remain anonymous
1. Please fill out form as completely as possible. DO NOT USE PT NAMES
2. To be completed in full and emailed to direct to the safety committee -
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.” -
Date & Time of Near Miss:
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Select the category the near-miss most relates to:
- Medicine error
- Equipment error
- Traffic safety
- Crew quarters safety
- Other
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Briefly describe the near miss
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Describe what lead up to and caused the Near Miss.
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What was learned and how could this be prevented in the future
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Photo/s that can help explain the what, where, why, or the possible injury:
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Name and Signature (optional)
