Near Miss Reporting

Make your workplace SAFER!

Today’s Near-Miss could be tomorrow’s major accident.

Click he ink below to complete the form. When ready, just click submit. It’s that easy!

Near Miss Form

Location: (BLDG #, Road, etc.)

Outside / Inside

Time of Incident

Date of Incident

MM

DD

YYYY

Select Appropriate Condition

Near Miss

Safety Concern

Safety Suggestion

Other

Type Of Concern

Describe the potential incident/hazard/concern and possible outcome )in as much detail as possible)

Safety Suggestion: (What could/should be done to eliminate this from ever happening?)

Name

First Name

Last Name

Email

Phone

(###)

###

####

Why does Near Miss Reporting even matter?

The near-miss program is designed to provide workers with the ability to make workplaces safer & reduce incidents and injuries.

It is everyone’s responsibility to report and correct any of these potential hazards immediately and without fear of retaliation.

•Reporting a near-miss, safety concern/suggestion is totally anonymous

•A report of near miss does NOT require a drug test.

BE HEARD! If you feel unsafe, say something.

Lookout for co-workers, yourself, your family!

Make your workplace SAFER!