Near Miss Report Form PDF Details

In the world of occupational safety, the Near Miss Report form serves as a pivotal tool, designed to address and document incidents that, while not resulting in injury, highlight potential dangers in the workplace. Developed by Workforce Safety & Insurance, this form aims to preemptively tackle unsafe working conditions, improper or unsafe use of equipment, and dangerous work habits that might lead to accidents. By encouraging the reporting and correction of these near misses, the form fosters a culture of safety and responsibility among employees and management alike. It requires detailed information about the incident, including the department, date, time, and a thorough description of the potential hazard. Additionally, it prompts an analysis of the near miss, asking for the causes and corrective actions taken or planned to mitigate the risk. Signatures from the reporting employee and management ensure accountability and follow-through. This structured approach not only aids in preventing future incidents but also promotes a proactive attitude towards workplace safety.

QuestionAnswer
Form NameNear Miss Report Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesnear miss form pdf, near miss reporting form samples, near miss reporting form, printable near miss reporting form

Form Preview Example

Workforce Safety & Insurance

www.WorkforceSafety.com

________________________________________________________________________________

NEAR MISS REPORT

A near miss is a potential hazard or incident that has not resulted in any personal injury . Unsafe working conditions, unsafe employee work habits, improper use of equipment or use of malfunctioning equipment have the potential to cause work related injuries. It is everyone’s responsibility to report and /or correct these potential accidents/incidents immediately. Please complete this form as a means to report these near-miss situations.

Department/Location ________________________________ Date: _____________________

Time ___________

am

pm

Please check all appropriate conditions:

Unsafe Act

Unsafe Condition

Unsafe equipment

Unsafe use of equipment

Description of incident or potential hazard : ___________________________________________

______________________________________________________________________________

______________________________________________________________________________

Employee Signature ___________________________________ Date _____________________

(optional)

NEAR MISS INVESTIGATION

Description of the near-miss condition: ______________________________________________

________________________________________________________________________________

Causes ( primary & contributing) ___________________________________________________

________________________________________________________________________________

Corrective action taken (Remove the hazard, replace, repair, or retrain in the proper procedures for the task)

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Signed: _________________________________________ Date Completed ______________

Not completed for the following reason: _______________________________________________

Management ________________________________________ Date _______________________

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near miss form conclusion process described (stage 1)

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Management  Date, Signed, and Date Completed of near miss form

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