Casey Greene

PCA - Near Miss

PCA Near Miss Form

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Print as PDF

Use this Template

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Title Page

Company
Client
Date
Location
Prepared By:
Category:
- Gravity - Suspended Load
- Gravity - Fall from Elevation
- Motion - Mobile Equipment and Workers on Foot
- Motion - Equipment / Vehicle Roll Over
- Motion - Motor Vehicle
- Mechanical - Heavy Rotating Equipment
- Temperature - High Temperature
- Temperature - Steam
- Temperature - Fire
- Pressure - Explosion
- Pressure - Excavation or Trench
- Electrical -Electrical Contact with Source
- Electrical - Arc Flash
- Environmental
- Chemical - High Dose of Toxic Chemical
- Chemical - Confined Space
- Work/Safety Procedure
- Quality Control
- Stored Energy - Line of Fire
Stored Energy - Line of Fire

Near Miss

Was Stop Work Authority utilized?
Event Description:
Corrective Actions:

Casey Greene

PCA - Near Miss

PCA Near Miss Form

Use this Template

Print as PDF

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.