Near Miss Form
A close call or near miss is a potential hazard or incident that has not resulted in any personal injury. Unsafe working condition, unsafe employee work habits, improper use of equipment or use of malfunctioning equipment have the potential to cause work related injuries. It is everyone's responsibility to report and/or correct these potential accidents/incidents immediately. Please complete this form as a means to report these near-miss situations.
Name:
*
First Name
Last Name
Email:
*
example@example.com
Department/Location
*
Date
*
-
Month
-
Day
Year
Date
Time
*
Hour Minutes
AM
PM
AM/PM Option
Please check all appropriate conditions:
*
Unsafe Act
Unsafe Condition
Unsafe equipment
Unsafe use of equipment
Other
Description of incident or potential hazard
*
Submit
Should be Empty: