SE & C LLC Near Miss Report - Rev 1

• Conducted on

  Date

• Prepared by

• Location
  Address

• Near Miss Defined
  OSHA and the National Safety Council defines a near miss as an “unplanned event that did not result in injury, illness or damage – but had the potential to do so.”

• Instructions:
  1. Required to be completed when you experience a Safety or Property Damage Near Miss in the workplace
  2. To be completed in full and emailed to direct to company Safety Director

Where & When

• Job number

• Date and Time

  Date

Incident/Near Miss Documentation

• Person(s) involved. Include all company and non-company person(s)

• What nearly happened - property damage, injury

  Select Property damage Injury

  • Property damage
  • Injury

• Property damage. Provide details about property involved. Personal, company, or host employer property.

• A photo will help explain the what, where, why. Upload the photo here:

  Media

• Describe what lead up to and caused the Near Miss. Identify root causes

• What was learned from the near miss?

• Details of corrective actions or behavior changes action taken

• A photo will help explain the what, where, why. Upload the photo here:

  Media

• Near injury most relates to:

  Select Fall from height Slip/trip same level Fall from equipment Falling object Material or tool handling Electric shock Caught between/underneath Hazardous material Other, describe below

  • Fall from height
  • Slip/trip same level
  • Fall from equipment
  • Falling object
  • Material or tool handling
  • Electric shock
  • Caught between/underneath
  • Hazardous material
  • Other, describe below

• Injury. Provide details about person involved. Limbs, torso, head

• Describe what lead up to and caused the Near Miss. Identify root causes

• What was learned from the near miss?

• Details of corrective actions or behavior changes action taken

• A photo will help explain the what, where, why, or the injury upload the picture here:

  Media

Communication

• Corrections actions or behavior changes were taken to prevent recurrence of near miss or incident

  Yes

  No

• Reasoning corrective action was not taken

• Near miss reported to supervisor. Yes or No

  Yes

  No

• Email completed report to company Safety Director

• Per company policy, promptly notify immediate supervisor. After review with immediate supervisor, revise answer to "yes" and proceed with report.