Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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At which plant did this occur?
- Albion
- Beatrice
- Brookhaven
- Fort Smith
- Greenville
- Loudon
- Pekin
- Winnebego
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Enter the date and time of the near miss
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Enter the name(s) of the employee involved
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Enter the exact location that the near miss occurred (B-Cut, Loading Station)
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Photo of location
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List any equipment that was involved
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Photo of equipment involved
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Was proper PPE being worn? (If no, explain why)
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Was company policy being followed? (If no, explain why)
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Description of the near miss
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Was a root cause analysis performed? (If no, explain why)
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List any corrective actions, disciplinary actions, extra training, etc. that is required due to the near miss
