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    Nearmiss Report Form

    Uploaded by

    Jafar Khan
    A near miss report form collects information about potential workplace hazards or incidents that did not result in injury. The form collects details about unsafe conditions, equipment issues, or behaviors that could cause accidents. Employees are responsible for promptly reporting near misses so they can be investigated and corrective actions can be taken to prevent future injuries. The investigation identifies the causes of the near miss and documents the corrective actions implemented to remove hazards or retrain employees.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Nearmiss Report Form

    Uploaded by

    Jafar Khan
    155 views1 page
    A near miss report form collects information about potential workplace hazards or incidents that did not result in injury. The form collects details about unsafe conditions, equipment issues, or behaviors that could cause accidents. Employees are responsible for promptly reporting near misses so they can be investigated and corrective actions can be taken to prevent future injuries. The investigation identifies the causes of the near miss and documents the corrective actions implemented to remove hazards or retrain employees.

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    NEAR MISS REPORT FORM

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    A near miss report form collects information about potential workplace hazards or incidents that did not result in injury. The form collects details about unsafe conditions, equipment issues, or behaviors that could cause accidents. Employees are responsible for promptly reporting near misses so they can be investigated and corrective actions can be taken to prevent future injuries. The investigation identifies the causes of the near miss and documents the corrective actions implemented to remove hazards or retrain employees.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    155 views1 page

    Nearmiss Report Form

    Uploaded by

    Jafar Khan
    A near miss report form collects information about potential workplace hazards or incidents that did not result in injury. The form collects details about unsafe conditions, equipment issues, or behaviors that could cause accidents. Employees are responsible for promptly reporting near misses so they can be investigated and corrective actions can be taken to prevent future injuries. The investigation identifies the causes of the near miss and documents the corrective actions implemented to remove hazards or retrain employees.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    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 everyones 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 equipment

    Unsafe Condition

    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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