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Near Miss Form Use Bottom of Form for Diagram if Necessary Date×Time of Issue or Potential Issue: Issue×Potential Issue Location: What happened: What Do You Think Is The Solution To This Problem:

How to fill out near miss form

1. Start by gathering all the relevant details: Before filling out the near miss form, make sure you have all the necessary information related to the incident. This may include the date and time of the near miss, the location, a description of what happened, and any contributing factors that may have led to the incident.
2. Clearly describe the near miss: In the form, provide a detailed description of the near miss. Include any relevant observations, actions taken, or potential consequences that could have occurred if the near miss had resulted in an actual accident or injury.
3. Identify the root cause: In order to prevent similar incidents from happening in the future, it is important to determine the underlying cause of the near miss. This may involve identifying any hazards in the work environment, equipment malfunctions, or human errors that contributed to the near miss.
4. Provide witness statements (if applicable): If there were any witnesses to the near miss, it is valuable to include their statements in the form. This can provide additional information or perspectives that may assist in the investigation or preventive measures.
5. Implement corrective actions: Suggest any corrective actions or recommendations that could help prevent a similar incident from occurring in the future. This may involve improving training programs, updating safety protocols, or addressing any identified hazards or issues.
6. Submit the near miss form: Once the form is complete, submit it to the appropriate authority. This may be a safety officer, manager, or designated person responsible for handling near miss reports within your organization.

Who needs a near miss form?

1. Employees: All employees, regardless of their position or department, should be aware of and have access to the near miss form. Encouraging employees to report near misses can contribute to a safer work environment and help prevent future accidents or injuries.
2. Safety and health department: The safety and health department within an organization is responsible for analyzing near miss reports and implementing preventive measures. They utilize the near miss forms to identify trends, evaluate risks, and develop strategies to improve workplace safety.
3. Management: Managers play a crucial role in promoting the reporting of near misses and ensuring that the appropriate actions are taken to address underlying issues. Near miss forms provide management with insights into potential risks, allowing them to allocate resources and implement changes to minimize future incidents.

In conclusion, filling out a near miss form involves describing the incident, identifying the root cause, providing witness statements (if applicable), suggesting corrective actions, and submitting the form to the appropriate authority. The near miss form is essential for employees, the safety and health department, and management in order to promote safety and prevent future accidents or injuries.

For pdfFiller’s FAQs

What is near miss form?

Near miss form is a document used to report incidents that did not result in injury or damage, but had the potential to do so.

Who is required to file near miss form?

Any employee who witnesses or is involved in a near miss incident is required to file a near miss form.

How to fill out near miss form?

To fill out a near miss form, provide details about the incident such as date, time, location, description of what happened, and any contributing factors.

What is the purpose of near miss form?

The purpose of near miss form is to identify potential hazards and prevent future incidents from occurring.

What information must be reported on near miss form?

Information that must be reported on near miss form includes details of the incident, contributing factors, corrective actions taken, and recommendations for prevention.

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