NEAR MISS REPORT

SITE / FACTORY: TIME OF ACCIDENT:

Employee Number: DATE OF ACCIDENT:
Name of the Person Involved: Age: Gender:
Location of the accident: Immediate Superior:
Occupation: Supervisor Contact:
Company: AMG
Type of incident in brief:
STATUS OF THE EMPLOYEE AT THE TIME OF ACCIDENT YES NO N/A
Was the employee authorized to carry out this job?
Was the employee trained on doing this job?
Was the employee being supervised at the time of accident?
Was the equipment, tools being used?
Was the employee using proper PPE?
Was the machine guarded? Was guard in place at the time of accident?
Was the energy source (electricity, compressed air) on machinery?
Was the employee servicing, isolated at the time of accident?
Was the injured employee working on scaffold more than 2 meter?
Was the area below barricated to restrict entry?
Was caution signage in place?

ENVIRONMENTAL CONDITIONS:

Atmosphere: Wet Dry Hot Cold Storm Rain Mist

Lighting in accident location: Good Poor Natural Dark
Floor Condition: Leveled Unleveled Watery Slippery Scattered Materials

Names of Witnesses:
SN NAME OCCUPATION COMPANY ID
1
2

DESCRIPTION OF THE NEAR MISS INCIDENT:

QA-AMG-FORM-014-2021
 INCIDENT CAUSES
UNSAFE PRACTICE BY THE EMPLOYEE(s):

UNSAFE WORKING CONDITIONS:

RECOMMENDED CORRECTIVE ACTIONS TO PREVENT OCCURRENCE OF SIMILAR ACCIDENT:

PREPARED BY: SIGNATURE DESIGNATION DATE

VERIFIED BY: SIGNATURE DESIGNATION DATE

QA-AMG-FORM-014-2021