NEAR MISS INCIDENT REPORT FORM

ACOUSTICS
10750 XYLON AVE N, SUITE 140, BROOKLYN PARK MN MAIN: 763.544.8901
NEAR MISS INCIDENT REPORT FORM
Department
Date of Incident

MonthDayYear
Date
Time of Incident

Hour Minutes

AM/PM Option
Work area or Jobsite
Witnesses optional
Type of Near Miss

Near MissSafety ConcernSafety Idea or SuggestionOther
Type of Concern

Unsafe ActUnsafe Condition of areaUnsafe Condition of EquipmentUnsafe Use of EquipmentSafety Policy ViolationOther
Describe the potential incident hazard concern and possible outcome be detailed
Were safety procedures violated describe
Job Name
Jobsite Address
Job
Job Project Manager
Incident site inspection Why was an unsafe act committed or why was the unsafe condition present
Recommendations or steps to take to prevent a similar incident
Reporters Name
Date Reported

MonthDayYear
Date
Additional Comments
Safety Manager - Ryan Grefsheim - 763.458.3137 - ryang@aaimn.com Safety Specialist - Nina Hennen - 763.200.2616 - kristinah@aaimn.com Panel Shop Superintendent - Jamey Johnson - 763.286.7117 - panelshop@aaimn.com Carpenter Superintendent - Craig Serfas - 763.286.8223 - craig.s@aaimn.com Flooring Superintendent - Craig Gunderson - 763.286.8484 - gundy@aaimn.com Tile/Concrete Superintendent - Rodney Baldwin - 763.286.8213 - rodney@aaimn.com
Should be Empty: