Get the free Near-Miss Accident Investigation Form - dickinson.edu

Name Print Signature Save Print When finished click here to automatically return form to the Department of Compliance Enterprise Risk Management Submit Form Page 1 of 1 Date. Near-Miss Accident Investigation Form Return to the Director of Compliance Enterprise Risk Management within two business days of the incident 1 INCIDENT INFORMATION EMPLOYEE NAME Select One DAY OF THE WEEK JOB TITLE DATE LOCATION BUILDING INTERIOR OR EXTERIOR DEPARTMENT FLOOR ROOM NO. 2 NEAR MISS SECTION If you...

How to fill out near-miss accident investigation form

How to fill out near-miss accident investigation form

1. Begin by gathering all necessary information about the near-miss incident, such as date, time, location, and description.
2. Identify the individuals involved in or witness to the near-miss accident and record their names, job titles, and contact details.
3. Describe the sequence of events leading up to the near-miss incident in a chronological order.
4. Include specific details and factors that contributed to the near-miss accident, such as unsafe conditions, equipment malfunctions, or human errors.
5. Evaluate the potential severity and consequences of the near-miss accident, and indicate the level of risk it posed.
6. Propose recommendations and corrective actions to prevent similar incidents from occurring in the future.
7. Review and verify the accuracy of all information provided in the near-miss accident investigation form.
8. Submit the completed form to the appropriate authorities or designated persons responsible for analyzing and addressing near-miss incidents.

Who needs near-miss accident investigation form?

1. Near-miss accident investigation forms are typically required by organizations and workplaces that prioritize safety and aim to prevent accidents.
2. These forms are necessary for employers, managers, and safety personnel to assess and investigate near-miss incidents, identify potential hazards, and implement preventive measures.
3. Employees who have witnessed or been involved in a near-miss accident may also need to fill out these forms to provide detailed information about the incident for analysis and improvement purposes.
4. Regulatory bodies and safety committees may also require near-miss accident investigation forms to monitor trends, evaluate safety practices, and enforce compliance with safety regulations.

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