Near Miss Report Format Form – Fill Out and Use This PDF

Nearly missing something important is a situation no one ever wants to experience. Creating a near miss report with consistent, clear and concise format is essential to alert and inform those in your organization of said incident while taking the necessary preventative steps needed to avoid future occurrences. Our Near Miss Reporting Form ensures that the reporting of close calls and near misses becomes a seamless part of your company's day to day operations. By laying out meaningful information in an organized way, it makes follow up investigations easier as everyone stays focused on accurate details and meticulously accounts for any quantifiable data/evidence collected following an incident. Utilizing this form helps to maintain a sense of accountability throughout the incident response process which allows all involved parties to move forward with confidence knowing that safety commitments have been kept.

Near Miss Report Format Form PDF Details

When completing a near miss report, it’s essential to choose the right format form to ensure that all necessary information is included. The goal of such reports is to identify situations where potential harm could have occurred and analyze how they can be avoided in the future. By being aware of these opportunities for prevention, organizations can take proactive steps toward safety and accident prevention. While there are many formats available for near-miss incident reporting processes, this post looks at why using a set standard form like our Near Miss Report Format Form will allow you to track your incidents more effectively than ever before.

Question	Answer
Form Name	Near Miss Report Format Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	near 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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Near Miss Report Format Form – Fill Out and Use This PDF

Near Miss Report Format Form PDF Details

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How to Edit Near Miss Report Format Form Online for Free

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