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Near Miss Report Form
Near Miss Report Form
Failed items
Created actions
Incident Report No.
Conducted on

1st Nov, 2018

5:15 PM PST

Employee Name (optional):
Lilly Singer
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:

1st Nov, 2018

4:30 PM PST

Location of Near Miss. If customer site, please provide address
warehouse second quadrant
Select the category the near-miss most relates to:
Electric Shock
Describe how the Near Miss occurred (include the body part and type of pain):
Dean Sammy's right hand was electrocuted while using the drill.
Describe what lead up to and caused the Near Miss. Identify root causes:
Cable appears to be damaged already.
What was learned and changed due to the Near Miss?
The equipment was stored and tagged not for repair.
Photo/s that can help explain the what, where, why, or the possible injury:
Name and Signature (optional)
Lilly Singer
1st Nov, 2018 5:21 PM PST
Media summary
1 Media file