NEAR MISS - NEAR HIT
REPORT
WHO
Was it us or another contractor?
*
Us
Someone else
Who is the Project Manager?
*
Greg Fredlund
Mike Poot
Roger Thorkelson
Pete Mc:Laughlin
Matt Demarchi
Brantley Grekoff
WHAT
Type of Near Miss:
*
Potential harm to body
Potential harm to property/material
Potential harm to vehicle
Other
What happened?
*
WHERE
Jobsite or Location:
*
Exact location:
*
WHEN
Date:
*
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
WHY
Check all contributing factors:
*
Distraction
Vague instructions
Poor communication
Mentally tired
Physically tired
Time pressure
Peer pressure
Never done the task before
Rarely do the task
Overconfidence
Mother nature
Tool maintenance
Wrong tool
No tool
No training
Other
OPTIONAL - Add a photo:
OPTIONAL - Your name
Type your email in below if you"d like a copy of this report:
Submit
Should be Empty: