Team Industries Report of Near Miss

• Prepared by

• Conducted on

  Date

REPORT OF NEAR MISS

• Employee Name:

• Employee Number:

• Shift:

  First

  Second

  Weeken

• Department (occurred) :

  Select Carbon 1 Carbon 2 Carbon 3 Carbon 4 Stainless Tank / Plate Loading Paint / Blast Receiving Maintenance QC Oconto Falls Texas

  • Carbon 1
  • Carbon 2
  • Carbon 3
  • Carbon 4
  • Stainless
  • Tank / Plate
  • Loading
  • Paint / Blast
  • Receiving
  • Maintenance
  • QC
  • Oconto Falls
  • Texas

ACTION:

• Hazard ID

• Unsafe Act / Behavior

• Unsafe Condition

• Unsafe Equipment

• Unsafe use of Equipment

• Other

RELATED TO:

• Powered Industrial Truck

• Rigging / Cranes

• PPE

• Wagons / Trailers

• Hand / Power Tools

• Cutting / Grinding

• Machinery

• LOTO

• Confined Space

• Fall Protection

• Material Handling

• Other

• Description:

• Corrective Action (s):

• Coached Employee ?

  Yes

  No

  N/A

• Follow - Up Needed ?

  Yes

  No

  N/A

• Photo:

  Media