CS Near Miss Report
CS Construction, Inc.
Name (Optional)
First & Last Name
Division/Job Number
*
Ex: B1762, DIV 3, etc
Date
*
-
Month
-
Day
Year
Observation Date
What Type of Observation Did You Make?
*
Physical Hazard (e.g., spills, exposed wires, clutter)
Equipment Issue (e.g., malfunction, missing guards)
Unsafe Behavior (e.g., not following procedures, lack of PPE)
Environmental Hazard (e.g., poor lighting, extreme temperatures)
The Team was Working Safe Today (e.g., proper PPE use, following safety protocols)
Where Did This Observation Occur?
*
Office Area
Warehouse/Storage
Outdoor Jobsite
Break Room/Common Area
Other (Please Describe In Notes)
Who or What Was Primarily Involved In The Observation?
*
Worker/Employee
Contractor
Visitor
Equipment/Machinery
Facility/Environment
What Was The Potential Impact of This Observation?
*
Could Cause Injury
Could Damage Equipment
Could Disrupt Operations
No Immediate Risk But Needs Attention
Positive Impact Due To Safe Practices
What Action Do You Recommend Based On This Observation?
*
Repair Equipment
Provide Additional Training
Install Signage/Barriers
Conduct Safety Audit
Recognize Individual/Team For Safe Practices
Notes (Describe/Give Details As Needed)
If Necessary
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