Near Miss Reporting Form
Person Submitting Form (Optional)
Providing a name will allow for a more complete follow-up and understanding of the situation, but is not required.
Date
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Month
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Day
Year
Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Weather
Dry/None
Fog
Ice
Overcast
Rain
Snow
Windy
Job Site
*
Department
*
ASBESTOS
GENERAL CONSTRUCTION
CONCRETE
OFFICE
OTHER
Description of Event
*
Please provide a detailed description of your concerns. The more details included the better we will be able to address the issue.
Characteristic
*
NEAR COLLISION
NEAR DAMAGE/BREAKDOWN
NEAR DISRUPTION OF OPERATION
NEAR FALL
NEAR FIRE/EXPLOSION
NEAR FLOODING
NEAR INJURY/THREATENED PERSONAL SAFETY
NEAR POLLUTION/SPILL
NEAR STEERING LOSS
SAFETY MEETING REPORT
UNEXPECTED EQUIPMENT FAILURE
How would you characterize the near miss?
What would you consider the root causes? (Check all that may apply)
*
Communication - Misunderstood
Communication - No Communication
Communication - Not Timely
Complex System - Monitoring Too Many Factors
Equipment - Not Available
Equipment - Controls Need Improvement
Equipment - Difficulty
Equipment - Display Needs Improvement
Equipment - Environment Not Considered
Equipment - Labels Need Improvement
Equipment - Maintenance Needs Improvement
Fatigue
Housekeeping
Human Performance Difficulty
Improperly Secured Gear
JSA/Personal Safety Check Not Performed
Lack of Foresight
Lack of Training
Natural Disaster
Oversight/Audit Needs Improvement
Procedure - Followed Incorrectly
Procedure - Missing
Procedure - Needs Improvement
Procedure - Not Used/Followed
Quality Control
Tool Selection - Needs Improvement
Training - Needs Improvement
Weather
Work Direction - Preparation Needs Improvement
Work Environment - Cramped Quarters
Work Environment - Crew Coordination Lacking
Work Environment - Lighting
Work Environment - Noise
Work Environment - Wet/Slick
Other
Immediate Action Taken
*
Please describe any immediate action taken (i.e. reporting to supervisor, removed the hazard, held safety meeting, etc.)
Suggestions for the Future
*
Do you have any ideas on how to prevent or eliminate this hazard for the future?
Submit
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