SAFETY & RISK
Near-Miss Report Form
Checklist Items
1
Date and time of near-miss incident accurately recorded
Pass/Fail
Required
2
Location of incident clearly identified
Pass/Fail
Required
3
Type of near-miss incident
Multiple Choice
Required
- Slip/Trip/Fall
- Equipment Related
- Chemical Exposure
- Fire/Explosion
- Vehicle/Transportation
- Ergonomic/Manual Handling
- Other
4
Number of people involved or at risk
Numeric
Required
Min: 1 people
5
Detailed description of what happened provided
Pass/Fail
Required
6
Immediate actions taken to prevent incident documented
Pass/Fail
Required
7
Root cause analysis completed
Pass/Fail
Required
8
Contributing factors identified
Pass/Fail
Required
9
Potential severity if incident had occurred
Multiple Choice
Required
- Minor Injury/Damage
- Major Injury/Damage
- Critical Injury/Extensive Damage
- Potential Fatality/Catastrophic
10
Corrective actions identified and assigned
Pass/Fail
Required
11
Target completion date for corrective actions set
Pass/Fail
Required
12
Responsible person assigned for follow-up
Pass/Fail
Required
13
Lessons learned documented for sharing
Pass/Fail
Required
14
Report reviewed and approved by supervisor
Signature
Required
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