Near Miss Report Form PDF Details

Do you know what a near miss report form is? Near misses are unplanned events that did not result in injury, damage, or loss - but had the potential to do so. As a business owner, it's important to recognize and address these types of occurrences to reduce the risk of further accidents or incidents occurring in your workplace. Filling out a near miss report form can be an effective way for employers and employees alike to keep track of any close calls and use the findings to improve safety protocols. In this blog post, we'll take a look at why it pays (literally!) for businesses to complete near miss reports and discuss various methods for doing just that. So let's get started!

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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1. The near miss form pdf usually requires particular information to be inserted. Make certain the subsequent fields are complete:

near miss form conclusion process described (stage 1)

2. Once the last array of fields is complete, you need to add the essential particulars in Signed, Date Completed, Not completed for the following, and Management Date allowing you to move forward further.

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

You can easily make a mistake while completing the Management Date, and so ensure that you reread it prior to when you submit it.

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