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Near Miss Report Form: DO NOT Include Any Names)

The document is a near miss report form for an Oldcastle Materials Company facility. It collects information about a near miss incident including the location, date, time, description of the near miss, corrective actions taken, and any additional comments. The form is designed to anonymously report close call incidents to identify areas for preventative measures in order to minimize the potential for accidents and injuries.

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51 views

Near Miss Report Form: DO NOT Include Any Names)

The document is a near miss report form for an Oldcastle Materials Company facility. It collects information about a near miss incident including the location, date, time, description of the near miss, corrective actions taken, and any additional comments. The form is designed to anonymously report close call incidents to identify areas for preventative measures in order to minimize the potential for accidents and injuries.

Uploaded by

Love
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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An Oldcastle Materials Company

An Oldcastle Materials Company

NEAR MISS REPORT FORM


FACILITY LOCATION: ______________________________________________________________
MANAGERS NAME: _______________________________________________________________
PERSON(S) REPORTING NEAR MISS: _______________________________________________
(Please Print)

DATE: ___________________________
MANAGER NOTIFIED:

TIME OF INCIDENT: _________________________

YES___________ NO___________

DESCRIBE NEAR MISS (DO NOT include any names):


________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

EXPLAIN CORRECTIVE ACTION TAKEN:


CORRECTIVE
ACTION
TAKEN
(Explain):
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
COMMENTS / OTHER: _____________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Reported By:

Reporters Signature

Date

Note: DO NOT IDENTIFY ANY EMPLOYEE(S) NAME(S) INVOLVED WITH THE NEAR MISS. This form will be used
as a proactive tool to assist with the prevention of future accidents and injuries by identifying close call and near miss
incidents and implementing corrective measures to minimize the potential for a reoccurrence.

Fax
completed
report to
Barbie Trinch
(386)
267-1338
***CLICK
TO AUTO
SUBMIT
FORM@BY
EMAIL***
:CYDI/intranet/forms/safety/near-miss report

Revised May 2010

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