TBG Safety: Good Catch/Near Miss Form

Good Catch/Near Miss Form
Date of Incident*

MonthDayYear
Date
Time of Incident*

Hour Minutes

AM/PM Option
Job Name*
Job Number*
Submitters Name*
Title of Submitter*
Submitters Telephone*
Please enter a valid phone number.
Submitters Email*
example@example.com
Name of Individual(s) Involved*
Title/Position of Individual(s) Involved
Witness Name
Witness Phone Number
Good Catch/Near Miss Location – Site of Incident Building Name, Room #, Stairs, Hallways, etc If Outside of Building, Give Location in Reference to Nearest Building.*
Good Catch/Near Miss Description (Fully Describe the Protocol/Procedures Being Followed Including All Substances/ Equipment, and Machinery Being Used Related to the Near Miss)*
Personal Protective Equipment (PPE) Used (If Applicable)
What was done to correct the situation?
Upload pictures and documentation if applicable

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Should be Empty:

Good Catch/Near Miss Form