NEAR MISS Reporting Form

NEAR MISS Reporting Form

NEAR MISS Reporting Form

Type of Near Miss:  Hot surface  Slippery floors  Trip over extension line  Forklift  Falling Object  Bad practice  Others. Please describe__________________  describe__________________  Date of Incident: Time of Incident:

extension line Type of Near Miss:  Hot surface  Slippery floors  Trip over extension  Forklift  Falling Object  Bad practice  Others. Please describe__________________  describe__________________  Date of Incident: Time of Incident:

Location:

Location:

Injuries? Yes / No

Persons Involved in Near Miss Incident: Names Department/ Company

Contact Number

Persons Involved in Near Miss Incident: Names Department/ Company

Contact Number

Other Witnesses:

Other Witnesses: Names

Injuries? Yes / No

Department/ Company

Contact Number

 Briefly describe describe what what happened happened including including the the sequence sequence of events. events. Safety & Compliance Compliance Manager Manager and and JH & S Committee will investigate scene of incident or near miss; conditions present at time of incident; what was involved, what activity (if any) was taking place prior and at time of incident. What hazards was the worker exposed to? What hazards may have contributed to the incident occurring? (Attach photos if available)

 Near Miss Incident #________________ #________________

Names

Department/ Company

Contact Number

 Briefly describe describe what what happened happened including including the the sequence sequence of events. events. Safety & Compliance Compliance Manager Manager and and JH & S Committee will investigate scene of incident or near miss; conditions present at time of incident; what was involved, what activity (if any) was taking place prior and at time of incident. What hazards was the worker exposed to? What hazards may have contributed to the incident occurring? (Attach photos if available)

 Near Miss Incident #________________ #________________

NEAR MISS Investigation Form

NEAR MISS Investigation Form

What preventative action should have been taken? Why was this action not taken?

What preventative action should have been taken? Why was this action not taken?

What contributing factors were there? (Lack of experience, adverse conditions, etc.)

What contributing factors were there? (Lack of experience, adverse conditions, etc.)

Recommendations Resulting from Investigation

Recommendations Resulting from Investigation

#1-

#1-

#2

#2

#3

#3

Recommendation #

EHS Department

Person Responsible

Signature

 Near Miss Incident #_______________

Completion Date

Review Date

Date

Recommendation #

EHS Department

Person Responsible

Signature

 Near Miss Incident #_______________

Completion Date

Review Date

Date