Near-Miss Report

A “NEAR-MISS” is a potential hazard or incident that has not resulted in any personal injury. Unsafe working conditions, unsafe employee work habits, improper use of equipment or use of malfunctioning equipment have the potential to cause work related injuries. It is everyone’s responsibility to report and/or correct these potential accidents/incidents immediately. Please, complete this form as a means to report these “NEAR-MISS” situations.

Region*
Select your location
Incident Date*
Date Format: MM slash DD slash YYYY
Date Reported
Date Format: MM slash DD slash YYYY
Time

: HH

MM
Department/Location
Nature of Condition
(i.e.: Unsafe Act, Unsafe Condition, Unsafe Equipment, Unsafe use of Equipment)
Description of Incident or Potential Hazard
Employee Name*
First Last
Witnesses
NEAR-MISS INVESTIGATION
Description of the “NEAR-MISS” Condition
Causes (Primary & Contributing)
Corrective action taken
(Remove the Hazard, Replace, Repair or Retrain in the proper procedures for the Task)
Investigated by:*
First Last
District Manager:
First Last
Date Completed
Date Format: MM slash DD slash YYYY
Not completed for the following reasons
MARC CAMACHO – HSE / Fleet Mgr.
Cell: 956-874-4530
Email: mcamacho@pipe-pros.com

Near-Miss Report

NEAR-MISS INVESTIGATION