Near Miss Report

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

NEAR MISS REPORT

No Disciplinary Action will be Taken for Reporting Near Misses

• Date and Time of Incident

  Date

• Day of Week

• Type of Work

  Select Regular Job Task Trouble Call Overtime

  • Regular Job Task
  • Trouble Call
  • Overtime

• Number of Hours Worked or On Duty Since Last Rest

• Number of Crew Members at Job Site

• Number of Potential Injuries

• Location of Incident
  Address

• Weather Conditions

• Vehicle/Equipment Damaged

  Select Bucket Digger Pick-Up Other

  • Bucket
  • Digger
  • Pick-Up
  • Other

• If Other, List the Type of Vehicle or Equipment

• Cause of Incident

  Select Equipment Failure Human Error Work Practice/Procedure Weather Unknown

  • Equipment Failure
  • Human Error
  • Work Practice/Procedure
  • Weather
  • Unknown

• Summary of Incident (no name required)

• Diagram of Incident

  Drawing

• Was Safety Equipment Provided?

  Yes

  No

  N/A

• Was Safety Equipment Used at Time of Incident?

  Yes

  No

  N/A

• Do You have a Policy/Safety Rule Pertaining to this Incident?

  Yes

  No

  N/A

• If Yes to Above Question, Please List

• What has been done to prevent re-occurrence?

• Reported By (optional)

  Sign

• Date and Time of Report

  Date