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MODEL NEAR MISS REPORTING FORM
Primary Source
Before you use this tool, you may want to read the further analysis presented here.
Benefits
Near misses are a valuable source of information for safety coordinators because they provide an opportunity for you to identify hazards or weaknesses in your OHS program and make corrections to prevent future incidents. But near misses are only valuable if you know about them. So you should require workers to report near misses immediately to their supervisors.
How to Use This Tool
Adapt this near miss reporting form and instruct workers to use it to report all near misses. The form can also be used to document the investigation into a reported near miss.
MODEL NEAR MISS REPORTING FORM
Definition: A near miss is an opportunity to improve health and safety in a workplace based on a condition or an incident with potential for more serious consequences.Examples of near misses: unsafe workingconditions, unsafe work habits, improper use of equipment or use of malfunctioning or broken equipment.
It’s everyone’s responsibility to report near misses immediately. Please complete this form to report all nearmisses. Failure to report a near miss may result in discipline.
Department/Location:______
Date: ______
Time:______
Please check all appropriate conditions:
[ ] Unsafe act [ ] Unsafe equipment[ ] Unsafe condition
[ ] Unsafe use of equipment[ ] Other—describe: ______
Description of incident or potential hazard:_______
______
______
Worker Signature:______Date:______
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NEAR MISS INVESTIGATION
Description of the nearmiss:______
______
Causes (directroot):______
______
Corrective action taken:______
______
Signed:______Date Completed:______
Not completed for the following reason(s):______
______
Management Signature:______Date:______
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