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Clear Form Hazard/Near-Miss Report Please write clearly in BLOCK LETTERS Reporting Person to complete and forward to your immediate Supervisor Dept/Divison Your Name Supervisor Phone Brief description of the Hazard/Near-Miss situation If insufficient space please attach a memo and/or diagram Subsequent action taken / to be taken / recommended by Reporting Person Signature Date Supervisor to complete and forward to the Director of Safety Title Director of Safety to complete and forward the...
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How to fill out hazard near miss form
How to fill out hazard near miss form
01
Read the instructions on the hazard near miss form carefully.
02
Provide accurate and detailed information about the hazard or near-miss incident.
03
Start by stating the date and time of the incident.
04
Describe the location and nature of the hazard or near-miss incident.
05
Explain the factors that contributed to the incident.
06
Provide any relevant background information or context.
07
Include information about any injuries or damages caused, if applicable.
08
Attach any supporting documents or evidence, such as photographs or witness statements.
09
Submit the completed hazard near miss form to the designated authority or responsible person.
10
Follow up with any additional information or updates, if required.
Who needs hazard near miss form?
01
Employees or workers who have witnessed or experienced a hazard or near-miss incident.
02
Employers or supervisors who need to track and address workplace safety issues.
03
Safety committees or organizations responsible for analyzing and mitigating risks.
04
Regulatory bodies or authorities concerned with enforcing safety regulations.
05
Insurance companies or risk management professionals evaluating workplace safety measures.
06
Any individual or entity committed to maintaining a safe and secure working environment.
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What is hazard near miss form?
The hazard near miss form is a document used to report incidents or situations that could have resulted in harm or damage but did not.
Who is required to file hazard near miss form?
All employees and contractors are required to file a hazard near miss form if they witness or are involved in a near miss incident.
How to fill out hazard near miss form?
To fill out a hazard near miss form, one must provide details of the incident, location, date and time, potential consequences, and any corrective actions taken.
What is the purpose of hazard near miss form?
The purpose of the hazard near miss form is to identify and address potential risks and prevent future incidents from occurring.
What information must be reported on hazard near miss form?
The hazard near miss form should include details of the incident, near miss description, contributing factors, and recommendations for improvement.
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