Get the free NEAR MISS STATEMENT FORM (Rev. 03-2021) Authorized ...

IF THERE IS MORE THAN ONE WITNESS PLEASE GIVE EACH WITNESS A COPY OF THIS FORM. THIS FORM MUST BE SUBMITTED TO RISK MANAGEMENT WITHIN 24 HOURS OF COMPLETION Email: Risk Management risk_management@hampton.govNEAR

How to fill out near miss statement form

How to fill out near miss statement form

1. Start by downloading the near miss statement form from the official website or obtaining a copy from your workplace.
2. Read the instructions provided along with the form to understand the information required.
3. Begin filling out the form by entering your personal details such as name, contact information, and job title.
4. Provide a detailed description of the near miss incident, including the date, time, and location of the event.
5. Explain the potential consequences or harm that could have resulted from the near miss.
6. Describe the contributing factors or hazards that led to the incident.
7. Include any witnesses or individuals involved in the near miss incident, and provide their contact details if possible.
8. Use clear and concise language to detail any actions taken after the incident to prevent future occurrences.
9. Review the completed form for accuracy and ensure all necessary information is included.
10. Sign and date the form to certify its authenticity and completeness.
11. Submit the filled-out near miss statement form to the designated authority or department as instructed.

Who needs near miss statement form?

1. Anyone who has witnessed or been involved in a near miss incident should fill out a near miss statement form.
2. This includes employees, contractors, visitors, or any individuals present at the time of the near miss.
3. Filling out the form helps in documenting and addressing the potential risks and hazards in the workplace, enabling proper investigation and preventive measures.

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What is near miss statement form?

A near miss statement form is a document used to report incidents that could have led to injury or damage but did not, allowing organizations to analyze the event and prevent future occurrences.

Who is required to file near miss statement form?

Typically, employees, supervisors, or safety officers are required to file a near miss statement form whenever they observe a near miss incident in the workplace.

How to fill out near miss statement form?

To fill out a near miss statement form, provide details such as the date and time of the incident, location, description of what happened, individuals involved, and any actions taken or recommendations for prevention.

What is the purpose of near miss statement form?

The purpose of a near miss statement form is to identify potential hazards, enhance workplace safety, implement preventive measures, and create a culture of safety awareness among employees.

What information must be reported on near miss statement form?

Information that must be reported includes the date and time of the near miss, location, description of the incident, people involved, contributing factors, and recommendations for improvement.