Fillable Printable Near Miss Reporting Template
Fillable Printable Near Miss Reporting Template
Near Miss Reporting Template
UPSO-NearMiss - REV 05/2011
Page 1 of 1
Near Miss Report
Questions about this form? Please call 701-231-7759
Near Miss: a potential hazard or an unplanned event that did not result in an injury, illness, exposure or damage - but had the potential
to do so. There was NO slip, trip, fall, punch, poke, bruise, strain, fire, or exposure.
Date: Time:
AM PM
Dept: Location:
Unsafe Condition
Unsafe Act/Behavior
Unsafe Equipment
Unsafe Use of Equipment
Check all that apply:
Description:
Employee Signature (optional) Date
Form Instructions
1. Within 24 hours the witness or person with knowledge of near miss/potential hazard must complete Section 1
2. Fax immediately to the safety office (231-6739)
3. The person who completed Section 1, must give form to their supervisor
4. Supervisor must conduct an investigation and complete Section 2
5. Upon supervisor's completion of Section 2, the entire form must be faxed to the safety office (231-6739)
Section 1 - Completed by witness or person with knowledge of near miss/potential hazard
Section 2 - Completed by supervisor after investigation of near miss/potential hazard
After the investigation, explain in detail what caused the potential hazard/near miss to exist/occur:
1. Primary and contributing factors and activities: (check all that apply)
Equipment
Equipment failure
Improper equipment or material used for job
Guard removed from equipment
Personal Protective Equipment
Not worn
Not readily available
Not adequate for the task
Personal protective equipment failure
Training/Experience
Lack of training
Failure to follow procedures
New task for employee or lack of experience
Incomplete Safe Operating Procedure
Outdated Safe Operating Procedure
Work Area
Work area set up improperly
Ergonomic factors
Ice or wet conditions
Lack of cord management
Loose handrails
Sanitary and housekeeping issues
Chipped tile or loose carpet/rug
3 foot clearance in front of electrical panel
Lack of Material Safety Data Sheets
Employee
Employee fatigue
Not paying attention
Going too fast
Taking short cuts
Unbalanced or poor position or motion
Improper footwear for conditions
Improper behavior and attitude
Poor housekeeping practices
Lack of policy/procedure
Not aware of surroundings
Disregard for safety rules
Animal (explain)
Other unsafe practice (explain):
Clear
Rain
Snow
Sleet
Hail
Other
2. Preventative Actions
Supervisor (must be completed)
Develop/revise safety policies/procedures and/or update plan
Remove equipment from use and repair or repair or replace
Retrain employee in proper procedures
Require personal protective equipment
Request ergonomic evaluation
Require Baseline Safety Training
Maintain housekeeping and sanitary conditions
Inform employee to slow down
Address employee work practices
Schedule preventative maintenance
Address attitude and behavior
Work Order completed
Contact Facilities Management (ice, etc)
Other (explain)
Supervisor or Manager Signature
NDSU Claims Management Specialist Signature
Date of Investigation
Date Received
Environmental Factors
Complete 1 & 2
Use additional pages as needed.
