Hazzard ID form

NEAR MISS AND HAZARDOUS CONDITION REPORT FORM

REV SEPT 12
Incident # (admin only)
Code(s) (admin only)
If at anytime during the working shift, you note a hazard condition, situation or practice, please report it to your supervisor immediately for corrective action, and document below
Type of Occurrence

Hazardous Condition Near Miss
Name of Person Completing Form
Date

Month Day Year
Date
Location (LSD, GSP, etc.)
Prime Contractor Company
Company Contact and Phone #
Job #
Description of Near Miss or Hazardous Condition
Near Miss or Hazardous condition classification

Class "A" - Potential loss of life or disability and/or extensive equipment, property damage Class "B" - Potential serious injury or temp. disability or property damage less than class A Class "C" - Potential of minor injury or illness or non-disruptive damage
Reported to
Corrective Action Taken
Corrective Action Taken by
Corrective Action Timeline

Corrected Immediately OR Date/Time:
Date

Month Day Year
Date
Time
Should be Empty:

NEAR MISS AND HAZARDOUS CONDITION REPORT FORM