Audit
Instructions:
1. Required to be completed when you experience a Safety Near Miss in the workplace
2. To be completed in full and emailed to direct manager or the Health & Safety Manager.
Near Miss Defined
OSHA and the National Safety Council defines a near miss as an “unplanned event that did not result in injury, illness or damage – but had the potential to do so.”
Date & Time of Near Miss:
Location of Near Miss. If customers site, please provide address
Select the category the near-miss most relates to:
Describe how the Near Miss occurred (include the body part and type of pain):
Describe what lead up to and caused the Near Miss. Identify root causes:
What was learned and changed due to the Near Miss?
If a photo will help explain the what, where, why, or the injury upload the picture here:
Choose your level of anonymity for this near miss report
By my signature below I attest that the information I have provided is true and accurate to the best of my knowledge:
Signature:
