An incident resulting in an injury or property damage b. Include a description of the event and, if needed, identify a root cause, associated hazards, andor add images. An example for when you are at work or in the office is when there was a nearmiss incident. Team members as a near miss management team establish causes prevent recurrences before they become recordable or serious establish corrective actions learn from the incident. Have a copy of your companys incidentreporting procedure and an incident investigation report for this discussion. Jan 22, 2020 safesite is a realtime near miss and incident reporting app. Immediately alert the responsible supervisor manager that a. Health and safety incident report form the incident reported by department email phone ext date of occurrence time exact location accident incident near miss violence ill health safety what happened. Employees must report a near miss using the companys near miss report form. But reporting near misses that happen on the job can be just as important as recording accidents. Supervisor report of accident pdf required for all injuries whether the injury is minor or requires medical care. The type of report form to be used for this case is an accident report form which will indicate the details of the occurrence. According to a fact sheet from osha and the national safety council, a near miss is an unplanned event that didnt result in damage, illness, or injury but had the propensity to do so. Many safety activities are reactive and not proactive, and some organizations wait for losses to.
This form should be completed whenever a near miss occurs that is an incident without injury to person or damage to property. An employee who witness es a near miss incident must complete the near miss. Employees also need to know what happens after they file a report. If personnel or property were injured or damaged during the incident, do no use this form. Please print clearly and legibly or use a computer to fill out form see last page for instructions. To report a near miss, fill out a short digital incident report form on desktop or mobile available for free on ios and android. People involved, including affected persons and witnesses. Nearaccidentsnearmisses are incidents that may or may not result in damage to property but do not result in an injury to employees or other.
If personnel were injured during the incident, do not use this form, use supervisors injuryillness report. Incident and injury report details of injury eg to a worker or visitor and treatment date of incident. Near miss report form a near miss is a potential hazard or incident that has not resulted in any personal injury or property damage. In near miss reporting promote kiewits culture of report near misses with the support and help of all managers and supervisors utilize c. The person involved or person filling in the report on their behalf is required to. A report form is a form where specific pieces of evidence and issues are being stated. Investigating a worksite incident a fatality, injury, illness, or close call provides employers and workers the opportunity to identify hazards. What actions, if any, could have been taken to prevent this incident from occurring. Incident report form annual credit report form expense report form hazard report form police report form injury report form daily report form maintenance report form death report. Firefighter near miss reporting system tools include a searchable database of near miss reports, packaged as training modules. A near miss should be reported to a supervisor since it may be. Some examples of nearmisses are unsafe conditions, improper use of equipment, use of faulty equipment, not following proper procedures. Recognizing, reporting and investigating near miss incidents can significantly improve worker safety and enhance an organizations safety culture.
Nearmiss report form a nearmiss is a potential hazard or incident that has not resulted in any personal injury or property damage. When most people think of workplace safety, they think of accidents, injuries, and fatalities. A near miss program creates the optimum perfect opportunity to capitalize on close calls. Noninjury and nearmiss incident reporting form instructions. It is used by safety teams to perform the following. Apr 19, 2018 for more ideas on how to structure your forms, check out our collection of near miss reporting form examples. One unique approach was to include nearmiss training during newemployee orientation while the project was being ramped up. Complete this form as soon as possible after an incident that results in serious injury or illness.
A near miss is an incident that occurred that could have resulted in an employee injury. The reporting system must be nonpunitive and anonymous. The near miss reporting process doesnt stop when employees hit submit, and neither should your near miss training. The person involved or person filling in the online report on their behalf is required to. Incidentnear miss investigation form the reason for investigating an incident or near miss is to determine. Reporting nearmisses reporting a nearmiss is an opportunity to teach others provided the researcher was not acting recklessly, no disciplinary action will be taken for reporting a nearmiss peerpressure should encourage, not discourage, reporting nearmisses your nearmiss report will be taken seriously by cebc leadership. The value of nearmiss reporting the intent of this discussion is to draw awareness to an important method of incident prevention. Nearaccidentnearmiss report environmental health and safety. Complete the online incident near miss hazard report. If an injury has occurred, use the incident reporting tool. There are a lot of uses of report forms and one of them is for those who witnessed an accident. Employees will report to the supervisor all incidents including near misses.
Near miss reporting arizona rock products association. Recognizing and reporting near miss incidents can significantly improve worker safety and enhance an organizations safety culture. A near miss is an unplanned event that did not result in injury, illness or damage, but it had the potential to do so. Near miss reporting systems national safety council. Document the details of the incident including location, equipment used, and people involved. Any unplanned event that did not cause an incident, but could, if conditions were to change c. An incident report form is a tool used to document any event that may or may not have caused personal injury and illness or property damage. But recognizing and reporting near misses can significantly improve worker safety.
Some examples of near misses are unsafe conditions, improper use of equipment, use of faulty equipment, not following proper procedures. Some organizations wait for losses to occur before taking steps to prevent them. Page 1 of 3 alfred university accident incident nearmiss investigation report please submit this form and all documentation to and notify ehs within 24 hours. Use additional paper as necessary and attach to form. This near miss report template is used to document near miss incidents to mitigate the risk and prevent recurrence.
Near miss reporting quiz multiple choice circle the correct answer. When near misses are reported and properly investigated, accident will be prevented, and early detection of failures will be enhanced. During this training, a full section was devoted to discussing nearmiss report ing barriers. Fillable and printable near miss reporting form 2020. Details about the incident such as hazards, objects, and threats involved. See page 2 for instructions in completing this form and definitions of terms marked with an asterisk. Writing report for near misses is not so different since it is equally an incident report. Learning objectives explain the reasons for reporting medication safety incidents state the types of reportable medication safety incidents. Use to investigate a minor injury or near miss that could have resulted in a serious injury or illness. Nearmiss, hazard and incident reporting guidelines. Please tick the appropriate box and mark with an arrow on body outline. A nearmiss is a potential hazard or incident that has not resulted in any personal injury or property damage.
633 401 250 678 1233 1516 1362 504 994 1047 1310 155 766 1230 100 756 664 853 1149 138 240 1208 452 151 716 555 253 1372 526 364 986 538 333 1035 544 859 13 534