INTERNATIONAL MARBLE CO.

LLC
NEAR-MISS REPORT FORM

A near-miss is a potential hazard or incident that has not resulted in any personal injury or
property damage. Some examples of near-misses are unsafe conditions, improper use of
equipment, use of faulty equipment, no following proper procedure, collapsing shelves, items
falling from height, charred or burnt electrical equipment or furniture, or a slip on a slippery
surface. It is everyone’s responsibility to report and correct any of these potential hazards
immediately.

Please use this form to report near-misses and assist us in preventing future incidents and
making IMC a safer workplace.

Head of Departments may complete the form on behalf of the person who witnessed the near-miss.
Department: Section:

Date of incident: Time of incident:

Mark all appropriate conditions: Type of concern:
 Near-miss  Unsafe act
 Safety concern  Unsafe condition of area
 Safety Suggestion  Unsafe condition of equipment
 Other (describe):  Unsafe use of equipment
 Other (describe):

Describe the potential incident/hazard/concern and possible outcome (in as much details as possible):

Safety Suggestions:

Reported By Name (Optional): Employee No. (Optional) Date Reported

Mobile Number (Optional) Email (Optional)

Submit this form to hse@intmarbleco.com or drop in the Suggestion Box

HSE/FT/12:00