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  • Near Miss Reporting Program: All Information Is Required

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    This document is a form for reporting near misses at a university. It collects information about the near miss such as date, location, and description of the unsafe act or condition. It also asks what led to the near miss and what steps will be taken to prevent similar incidents from occurring. The completed form is distributed to the Environmental Health and Safety department and relevant safety committee or department head to share lessons learned.

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    This document is a form for reporting near misses at a university. It collects information about the near miss such as date, location, and description of the unsafe act or condition. It also asks what led to the near miss and what steps will be taken to prevent similar incidents from occurring. The completed form is distributed to the Environmental Health and Safety department and relevant safety committee or department head to share lessons learned.

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    Near Miss Reporting Program: All Information Is Required

    Uploaded by

    Love
    This document is a form for reporting near misses at a university. It collects information about the near miss such as date, location, and description of the unsafe act or condition. It also asks what led to the near miss and what steps will be taken to prevent similar incidents from occurring. The completed form is distributed to the Environmental Health and Safety department and relevant safety committee or department head to share lessons learned.

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    Near Miss Reporting Program


    Near Miss Reporting is the process of identifying and preventing an unsafe act or unsafe condition before it causes an injury or illness. This form is used to formally document the recognition of a hazard, the change that is made to prevent a reoccurrence of the hazard and to share the lessons learned with the University Community.

    All information is required.


    Incident Date and Time: Contact Number: Name of Reporting Person: E-mail:

    Description of the near miss. Please explain the following: 1) Who was involved in the near miss 2) What exactly happened 3) Where did the near miss occur 4) When did the near miss occur 5) How did the near miss occur

    What acts or conditions led directly to the near miss incident?

    What steps have/will be taken to prevent a similar incident? Who is responsible for taking these actions and following up to see that they are complete? Expected Completion Date: Actual Completion Date:

    Distribution: 1) Joseph Miller, Environmental Health and Safety, 2) Departmental Safety Committee Chair and/or Department Head

    EHS USE ONLY EHS Notes and Comments

    September 23,2009

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