Near Miss Report

• Prepared by:

Employee Information:

• Name of Employee Invoved:

• Contact Number:

• Hire Date:

• Job Title:

• Did the Employee violate a safety or health regulation that lead to the near miss?

  Yes

  No

• Safety violation:

• Location of the Near Miss:
  Address

• Employee was performing work for:

  Select CPA North CPA South CPA Construction CPA O and M Peoples Natural Gas

  • CPA North
  • CPA South
  • CPA Construction
  • CPA O and M
  • Peoples Natural Gas

• Jobsite Foreman:

• Crew members involved:

• Any Witnesses?

  Yes

  No

• Name of Witness:

• Nearest Medical Facility:

Near Miss Classification:

• Type of Near Miss:

  Select Slips, Trips, Falls Struck By Caught in/ Between Electrical Shock Burn Fires/Explosion Trench Collapse Equipment Related Rollover/ Crushing Repetitive Motion Excessive Hot Temperatures Excessive Cold Temperatures Excessive Noise Exposure Respiratory Diseases

  • Slips, Trips, Falls
  • Struck By
  • Caught in/ Between
  • Electrical Shock
  • Burn
  • Fires/Explosion
  • Trench Collapse
  • Equipment Related
  • Rollover/ Crushing
  • Repetitive Motion
  • Excessive Hot Temperatures
  • Excessive Cold Temperatures
  • Excessive Noise Exposure
  • Respiratory Diseases

• Potential Body Part affected:

• Rate the likelihood of near miss reoccurence from 1-5:

• Rate the Severity of Potential injury or property damage from 1-5:

• Evaluate the level of risk associated with the near miss by multiplying liklihood by severity.

• From the Calculated number above, rank the near miss to provide an overall risk factor.

  0-5 Low Risk

  6-10 Moderate Risk

  11-15 High Risk

  16-25 Extremely High Unacceptable Risk

Employee Statement:

• Explain What happened in your own words:

Hazard Classification:

• What is the nature of the near miss?

  Select Slips, Trips, Falls Struck By Caught in/ Between Electrical Shock Burn Fires/Explosion Trench Collapse Equipment Related Rollover/ Crushing Repetitive Motion Excessive Hot Temperatures Excessive Cold Temperatures Excessive Noise Exposure Respiratory Diseases

  • Slips, Trips, Falls
  • Struck By
  • Caught in/ Between
  • Electrical Shock
  • Burn
  • Fires/Explosion
  • Trench Collapse
  • Equipment Related
  • Rollover/ Crushing
  • Repetitive Motion
  • Excessive Hot Temperatures
  • Excessive Cold Temperatures
  • Excessive Noise Exposure
  • Respiratory Diseases

Root Cause Investigation

• 1. What Happened?

• 2. Why did this happen? (Direct Cause)

• 3. Why did #2 happen? (unsafe act/condition/indirect cause)

• 4. Why did this unsafe act/condition/indirect cause happen?

• Root Cause of the Injury:

Corrective Actions

• What can we do to correct the root cause? How can we prevent the near miss from occuring in the future?

• Attached Pictures:

  Media

• Employee Signature:

  Sign

• Safety Manager Signature:

  Sign