Laserfiche WebLink
serlegm brityrviedServica, inc. Near Miss Report <br />Questions about this form? Please call 310-522-1168 <br />Near Miss: a potential hazard or an unplanned event that did not result in an injury, illness, exposure or damage - but had the potential <br />to do so. There was NO slip, trip, fall, punch, poke, bruise, strain, fire, or exposure. <br />Form Instructions <br />Within 24 hours the witness or person with knowledge of near miss/potential hazard must complete Section 1 <br />Within 24 hours notify the health and safety department of the near miss <br />The person who completed Section 1, must give form to their supervisor <br />Supervisor must conduct an investigation and complete Section 2 <br />Upon supervisor's completion of Section 2, the entire form must be Email to the health and safety department <br />Section 1- Completed by witness or person with knowledge of near miss/potential hazard <br />Date: Time: C AM C PM <br />Dept: Location: <br />Check all that apply: <br />Unsafe Condition n Unsafe Equipment Unsafe Use of Equipment El Unsafe Act/Behavior <br />Description: <br />Employee Name and Signature Date <br />Section 2 - Completed by supervisor after investigation of near miss/potential hazard <br />After the investigation, explain in detail what caused the potential hazard/near miss to exist/occur: <br />Equipment <br />0 Equipment failure <br />Improper equipment or material used for job <br />n Guard removed from equipment <br />Personal Protective Equipment <br />Not worn <br />D Not readily available <br />Not adequate for the task <br />Personal protective equipment failure <br />Training/Experience <br />0 Lack of training <br />D Failure to follow procedures <br />New task for employee or lack of experience <br />Incomplete Safe Operating Procedure <br />Outdated Safe Operating Procedure <br />Work Area <br />0 Work area set up improperly <br />0 Ergonomic factors <br />0 Sanitary and housekeeping issues <br />1:1 Lack of cord management <br />El Ice or wet conditions <br />D Loose handrails <br />D Chipped tile or loose carpet/rug <br />0 3 foot clearance in front of electrical panel <br />fl Lack of Material Safety Data Sheets <br />Employee <br />0 Employee fatigue <br />0 Unbalanced or poor position or motion <br />fl Not paying attention <br />D Improper footwear for conditions <br />ID Going too fast <br />Taking short cuts <br />0 Not aware of surroundings <br />Lack of policy/procedure <br />O Poor housekeeping practices <br />O Improper behavior and attitude <br />Disregard for safety rules <br />D Animal (explain) <br />Environmental Factors <br />0 Clear <br />fl Rain <br />fl Snow <br />0 Sleet <br />0 Hail <br />EI Other <br />1. Primary and contributing factors and ac tivities: (check all that apply) 2. Preventative Actions <br />Supervisor (must be completed) <br />Develop/revise safety policies/procedures and/or update plan <br />0 Request ergonomic evaluation <br />Require personal protective equipment <br />El Remove equipment from use and repair or repair or replace <br />D Schedule preventative maintenance <br />l Retrain employee in proper procedures <br />Require Baseline Safety Training <br />fl Inform employee to slow down <br />Address attitude and behavior <br />Address employee work practices <br />0 Maintain housekeeping and sanitary conditions <br />fl Work Order completed <br />O Contact Facilities Management (ice. etc) <br />0 Other (explain) <br />Complete 1 & 2 <br />Use additional pages as needed. <br />D Other unsafe practice (explain): <br />Supervisor or Manager Signature <br /> <br />Date ofInvestigation <br />Health and Safety Director Signature <br /> <br />Date Reviewed <br />AIS/H&S/REV1 02/2014 Page 1 of 1