OPTIMUS Near Miss and Incident Initial Safety Report

• The Safety Report tool is used to identify Hazards or Risks in the work area. Also used for identifying Near Miss incidents, PSIF Incidents, Injuries/Illnesses and documenting Safety Observations.

• FIRST NAME/LAST NAME OF EMPLOYEE INVOLVED

• Area

  Select
• Location
  Address

Information

• Date and Time

  Date

• Select the HSE Report Type

  Near Miss

  PSIF

  Injury/Illness

  OSHA Recordable

Description and Action Taken

• Potential

  Select Injury / Illness Environmental Vehicle Asset (equipment/materials)

  • Injury / Illness
  • Environmental
  • Vehicle
  • Asset (equipment/materials)

• Type of HSE hazard (Select all that apply

  Select Biohazard Exposure Chemical Handling Driving Drugs / Alcohol Fire / Explosives Handling (Using Hands) Manual Lifiting Mechanical Lifting Natural Phenomenon Noise Other Pressure Stepping (Walking) Temperature Extremes Working at Height Electrical Shock Inhalation Spill or Leak

  • Biohazard Exposure
  • Chemical Handling
  • Driving
  • Drugs / Alcohol
  • Fire / Explosives
  • Handling (Using Hands)
  • Manual Lifiting
  • Mechanical Lifting
  • Natural Phenomenon
  • Noise
  • Other
  • Pressure
  • Stepping (Walking)
  • Temperature Extremes
  • Working at Height
  • Electrical Shock
  • Inhalation
  • Spill or Leak

• Please describe the type of hazard.

• Give a description of the Observation, Near Miss, PSIF or Injury/Illness

• What were the actions taken to address the Observation, Near Miss, PSIF or Injury/Illness?

Follow Up

• is follow-up needed? - If any deficiencies above have not been addressed select "Yes"

  Yes

  No

• By selecting "No" to the previous question I am agreeing that I have fixed all deficiencies noted in this document.

• By selecting "Yes" to the previous question I am agreeing that I have assigned an action item as noted deficiencies were not been able to fix on the spot.