Title Page
Near Miss: An unplanned event that did not result in injury, illness or damage but had the potential to do so. For reporting purposes there are two categories of Near Misses being tracked. They are Close Call and Good Catch. 1. Close Call - An event or circumstance that had the potential to cause an injury or severe property damage. No workers were injured or property was damaged due to luck. (Example: A worker at an elevated height drops a tool. No workers are injured and the tool was not damaged.) 2. Good Catch: An event or circumstance that had potential to cause an incident but did not actually occur due to timely intervention or corrective action taken. (Example: A worker is stopped before they can access an elevated work area without fall protection.) NOTE: This tool is designed for tracking Close Calls and Good Catches only. Hazardous Condition: A physical condition which if not corrected has the potential to cause injury. (Example: Lack of personal protective equipment, damaged electrical cord, missing rebar cap, etc.) If you are reporting a Hazardous Condition, discontinue use of this form and document the condition using iAudit or on the Daily Log. Serious Safety Violation: A willful violation of fall protection, exposure to live electrical parts or exposure to cave-in hazards per the Serious Safety Violation Policy. If you are reporting a Serious Safety Violation, discontinue use of this form and go to the safety page on Weitznet and use the Serious Safety Violation Investigation Report form to document the violation.
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Project Name
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Date Observed
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Prepared by
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The event I'm reporting is a:
- Close Call
- Good Catch
Close Call
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Date & Time this event occurred
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Provide a description of the "Close Call" Answer the following questions: Who, What, Where and How
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Why did this Close Call occur? (Root Cause)
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What Corrective Action was taken or proposed?
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Do you feel there is a valuable lesson to be learned as a result of this event and a How It Happened should be written? <br>If YES, Why?<br>If NO, why not?
Good Catch
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Was this good catch made by a Weitz or Subcontractor Employee(s)
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Name of employee(s) who made the Good Catch
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Provide a description of the Good Catch (What was observed, why was intervention required etc.)
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If this intervention was required as the result of an employee exposure to a hazard, what was the reason?
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Was the employee(s) recognized with positive recognition? <br>If YES, what was done?<br>If NO, what do you plan on doing to recognize the employee?
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If the employee(s) was recognized, what was the recognition?
