Near Miss Reporting Form

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*

MonthDayYear
Time

:HourMinutesAM/PM Option
Weather
Job Site*
Department*
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*
How would you characterize the near miss?
What would you consider the root causes? (Check all that may apply)*

Communication - MisunderstoodCommunication - No CommunicationCommunication - Not TimelyComplex System - Monitoring Too Many FactorsEquipment - Not AvailableEquipment - Controls Need ImprovementEquipment - DifficultyEquipment - Display Needs ImprovementEquipment - Environment Not ConsideredEquipment - Labels Need ImprovementEquipment - Maintenance Needs ImprovementFatigueHousekeepingHuman Performance DifficultyImproperly Secured GearJSA/Personal Safety Check Not PerformedLack of ForesightLack of TrainingNatural DisasterOversight/Audit Needs ImprovementProcedure - Followed IncorrectlyProcedure - MissingProcedure - Needs ImprovementProcedure - Not Used/FollowedQuality ControlTool Selection - Needs ImprovementTraining - Needs ImprovementWeatherWork Direction - Preparation Needs ImprovementWork Environment - Cramped QuartersWork Environment - Crew Coordination LackingWork Environment - LightingWork Environment - NoiseWork Environment - Wet/SlickOther
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?
Should be Empty: