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A <br />APEX <br />NEAR MISS REPORT FORM <br />Date of Near Miss: <br />Employer (include Apex-SGI subcontractors) <br />Company Name: <br />Address: <br />City, State, Zip: <br />Project Name: <br />Project Number: <br />Employee (include Apex-SGI subcontractors) <br />First and Last Name: <br />Employment Status: <br />Near Miss Information <br />Where did near miss occur? (number, street, city, state, zip): <br />Other people affected in this event?: <br />Description of Near Miss (Explain exactly how and what happened): <br />Root Cause and Contributing Factors (Describe in Detail Why Near Miss Occurred) <br /> <br /> <br />Root Cause(s) Analysis (RCA) - Use proactively to avoid Near Misses. <br />Lack of skill or knowledge. <br />Lack of or inadequate operational procedures or work standards. <br />Inadequate communication of expectations regarding procedures or work standards. <br />Inadequate tools or equipment. <br />Uncontrollable.