Safety Guide Near Miss Report

• Near Miss Reporting Form

• Conducted on

  Date

• Prepared by or originator

Information

• Name of person reporting the incident:

• Date of incident:

  Date

• Approximate time of incident:

  Date

• Your company:

• Location or job-site of incident:

• Company Observed: (if known)

• Area where observed:

• Name of supervisor of company observed: (if known)

• Name of Employee(s) observed:

Description of Near Miss

• What happened?

Corrective Action(s)

• List of corrective actions

Actions

• Comments:

• Select all that apply in the following list(s).

Potential Cause (Note: These are examples not all inclusive) .

• Select all that apply:

  Select Potential Strain Potential Struck By Potential Burn or Scald Potential Caught in Between Potential Slips, Trips or Falls Potential Foreign Object in Eye Potential Inhalation of Toxic Fumes Potential Scrapes, Punctures or Cuts Other

  • Potential Strain
  • Potential Struck By
  • Potential Burn or Scald
  • Potential Caught in Between
  • Potential Slips, Trips or Falls
  • Potential Foreign Object in Eye
  • Potential Inhalation of Toxic Fumes
  • Potential Scrapes, Punctures or Cuts
  • Other

• If the response is "Other" please explain.

Root Cause (Note: These are examples not all inclusive)

• Root Cause

  Select PPE Weather Environmental Housekeeping Lack of Training Poor Procedures Tools and Equipment Inattention to Detail Other

  • PPE
  • Weather
  • Environmental
  • Housekeeping
  • Lack of Training
  • Poor Procedures
  • Tools and Equipment
  • Inattention to Detail
  • Other

• If the response is "Other" please explain.

What can be done to prevent reoccurrence

• What can be done to prevent reoccurrence?

If further help or action is needed please describe

• If further help or action is needed please describe: