NEAR MISS FORM 25

Please fill out this form to report near-misses, helping us prevent future incidents and create a safer workplace.

DEPARTMENT

WORK AREA

DATE AND TIME OF INCIDENT

WITNESSES (OPTIONAL)

TYPE OF NEAR MISS TYPE OF NEAR MISS NEAR MISS SAFETY CONCERN SAFETY IDEA/SUGGESTION OTHER

CONCERN CONCERN UNSAFE ACT UNSAFE CONDITION UNSAFE CONDITION OF EQUIPMENT SAFETY POLICY VIOLATION OTHER

DESCRIBE NEAR MISS

DESCRIBE THE CONCERN

DESCRIBE THE POTENTIAL INCIDENT/HAZARD/CONCERN AND POSSIBLE OUTCOME (BE DETAILED)

WERE SAFETY PROCEDURES VIOLATED? (DESCRIBE)

RECOMMENDATIONS/STEPS TO TAKE TO PREVENT A SIMILAR INCIDENT

INCIDENT SITE INSPECTION - WHY WAS AN UNSAFE ACT COMITTED, OR WHY WAS THE UNSAFE CONDITION PRESENT?

NAME (OPTIONAL)

DATE REPORTED

SUPERVISOR SIGNATURE

DATE