Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Please provide address, specific location, customers name, below
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Location of Near Miss being Reported
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Team Members Name (optional)
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Supervisors Name:
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Serious Injury Fatality (S.I.F.) ?
- Yes
- No
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Serious Injury Fatality S.I.F. (Precursors)
- No 1 - Did the event involve exposure to acute failure, override, or a failure to use a critical safety feature on a piece of equipment?
- No 2 - Did the event involve exposure to a collapse, overturn or partial/complete failure of equipment/finished goods that was newly erected/built/tested or commissioned?
- No 3 - Did the event involve a Team Member exposure to a fall from height?
- No 4 - Did the event involve exposure to a release of hazardous energy due to ineffective lockout during maintenance, installation, inspection, repair, service or troubleshooting?
- No 5 - Did the event involve exposure to being crushed, trapped entangled or in the line of fire with either a release of significant energy or weight?
- No 6 - Did the event involve the movement of long and/or heavy unbalanced objects?
- No 7 - Did the event involve exposure to potential fire/explosion during hot work on a finished product or with an oxy-acetylene system?
- No 8 - Did the event involve potential or actual contact with "live" electricity?
- No 9 - Did the event involve potential or actual harm to a person from a motorized vehicle (includes operator and pedestrian)?
- No 10 - Was this an actual life altering, life threatening or fatal event?
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Type of Near Miss being reported ?
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*If other please list in here
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Description of Near Miss being reported:
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Insert photograph of Near Miss being reported here (please remember confidentiality and no TMs faces)
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Description of immediate corrective actions
