Near Miss Incident Form

  Date of Near Miss: __/__/ __ Time __: __ A.M. P.M. Time zone: ______  Reported by: ____________________
  Near Miss description: _______________________________________________________________________
  __________________________________________________________________________________________
  __________________________________________________________________________________________
  Site Name: ________________________________________________________________________________
  Address of Site: _____________________________________________  City: _________________________    
  State or Province: ____________________________________________ Country: ______________________
  WO #: ___________________________________________________________________________________
  Scope of Job: ______________________________________________________________________________
  __________________________________________________________________________________________

  Installation Manager: _________ Crew Leader: __________ Truck Number #: _______ Equipment #: _______

  Crew Members on Site: ______________________________________________________________________
  Eye Witnesses: ____________________________________________________________________________
  Star Witnesses: ____________________________________________________________________________
  Equipment involved: _________________________________________________________________________
  Vehicles involved: ___________________________________________________________________________
  Property involved: ___________________________________________________________________________
  Environment involved: ________________________________________________________________________
  Employees involved: _________________________________________________________________________
  General public involved: ______________________________________________________________________
  Sub-contractor involved: ______________________________________________________________________
  Outside contractor involved: ___________________________________________________________________

  Safety Issues to Discuss: ____________________________________________________________________
  __________________________________________________________________________________________
  __________________________________________________________________________________________

  Corrective Action: ___________________________________________________________________________
  __________________________________________________________________________________________

  Root Cause: _______________________________________________________________________________
  __________________________________________________________________________________________
  __________________________________________________________________________________________

  Trend analysis: _____________________________________________________________________________
  Remedial action: ____________________________________________________________________________
  Follow Up: _________________________________________________________________________________
  __________________________________________________________________________________________
  Management Analysis and Action: _____________________________________________________________
  __________________________________________________________________________________________
  Copy of Near Miss filed with: __________________________________________________________________
  Individuals notified regarding the Near Miss: ______________________________________________________
  __________________________________________________________________________________________
  Risk Manager provided a copy of this report: ___ yes ___ no    Date: ___ / ___ / ______
  Safety committee sign off: ____________________________________________________________________
  Company officer sign off: _________________________________________ Title: _______________________
  Copy put in secured administrative officer for insurance agent review: ___ yes ____ no  Date: ___ / ___ / ____
  Human Resources provided a copy of this report: ___ yes ___ no  Date: ___ / ___ / ______

  Risk Manager sign off: __________________________________________________ Date: ____ / ____ /_____
  President / CEO / Director sign off: ________________________________________ Date: ____ / ____ /_____

                        Safety is the Key
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