Near Miss Report Format Form PDF Details

In the proactive landscape of workplace safety, the Near-Miss Report Form serves as an essential tool in identifying and mitigating potential hazards before they escalate into serious incidents. By encouraging the reporting of close calls, which include anything from unsafe conditions and work habits to the improper use of or reactions to equipment, Texas Tech University upholds a commitment to fostering a secure environment for its community. This form is designed to be accessible and straightforward for all members of the university, encompassing faculty, staff, students, and others, allowing them to specify the nature of the near-miss, be it related to unsafe acts, conditions, equipment, or any other safety concerns. The detailed documentation of the incident—including department, location, time, and a thorough description of the potential hazard—is crucial for enabling the Environmental Health & Safety (EH&S) team to address and rectify the situation promptly. Moreover, the option for anonymous reporting ensures that individuals can voice their concerns without hesitation, reinforcing the culture of safety and vigilance. With every form submitted, Texas Tech University takes another step towards preventing future incidents, underscoring the collective responsibility for a safer campus environment.

QuestionAnswer
Form NameNear Miss Report Format Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesnear miss form template, printable near miss report template, construction near miss form, near miss form osha

Form Preview Example

Near-Miss Report Form

A near miss is a potential hazard or incident that has not resulted in any personal injury or property damage. Unsafe conditions, unsafe work habits, improper use of equipment, use of malfunctioning equipment, or unexpected reactions are examples of near-misses. It is everyone’s responsibility to report and correct these potential hazards immediately. Please complete this form as a means to report these near-miss situations and help prevent future incidents at Texas Tech University.

Department:

Building:

 

 

Room #:

Date of Incident:

 

 

 

 

 

 

Time of Incident:

 

Designation:

 

☐am ☐pm

☐Faculty ☐Staff ☐Student ☐Other:

 

 

 

 

 

 

Check all appropriate conditions:

 

 

Type of concern:

 

☐ Near miss

 

 

 

☐ Unsafe act

 

☐ Safety concern

 

 

 

☐ Unsafe condition

 

☐ Safety suggestion

 

 

 

☐ Unsafe equipment

 

☐ Other:

 

 

 

☐ Unsafe use of equipment

 

 

 

 

☐ Other:

 

 

 

 

 

 

 

Thoroughly describe the potential incident /hazard/concern (possible effects, etc) :

(Optional)

Date Reported:

Name:

 

 

 

Contact Information:

 

Submit this form to EH&S:

Environmental Health & Safety, Mailstop 1090, Administrative Support Center, Rm 122.

For questions or cases deemed immediately dangerous to life or health, call EH&S at (806) 742-3876.

In the case of an emergency, call 911 (9-911 from a landline).

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In order to complete this form, be sure you type in the required information in each and every blank:

1. You should complete the near miss card template accurately, so pay close attention when working with the parts containing all of these blanks:

construction near miss form completion process shown (stage 1)

2. The next stage would be to complete the next few blank fields: Thoroughly describe the potential, Date Reported, Contact Information, Environmental Health Safety, For questions or cases deemed, In the case of an emergency call, and Submit this form to EHS.

Writing segment 2 in construction near miss form

It is possible to make a mistake while filling in the Date Reported, consequently you'll want to go through it again prior to deciding to finalize the form.

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