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
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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
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Dry/None
Fog
Ice
Overcast
Rain
Snow
Windy
Job Site
*
Department
*
MIXER TRUCK
DUMP TRUCK
GENERAL CONSTRUCTION
IRONWORKER
SHOP
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 CONCERN
SAFETY SUGGESTION
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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