ALC Near Miss Safety Form
A near miss is a warning sign. Reporting it helps prevent injuries before they happen. No discipline for reporting — safety is everyone’s responsibility.
Date of Near Miss
*
-
Month
-
Day
Year
Time of Near Miss
*
Minutes
AM
PM
AM/PM Option
Jobsite name and/or job number
*
Specific area/floor
*
Your Name
I prefer to remain anonymous
I prefer to remain anonymous
What Happened? (Briefly describe the near miss event)
*
Photo documentation upload (optional)
Upload a File
Drag and drop files here
Choose a file
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What COULD HAVE happened? (Check all that apply)
*
Fall
Laceration
Electrical Shock
Struck by/Caught between
Equipment or Material damage
Slip/Trip
PPE Issue
Muscle Strain/Sprain
Other
Potential Severity (Check all that apply)
*
Minor Injury
Serious Injury
Fatality Potential
Property Damage
Immediate Action Taken (What was done right away to make the area safe?)
*
Suggested Prevention (What can we do to prevent this from happening again?)
*
Submit Report
Should be Empty: