Near Miss Investigation Report

A workplace hazard is any potential source of injury or property damage in the workplace. Workplace hazards can include unsafe conditions, damaged or improper equipment, inadequate procedures, missing safety equipment, and environmental contaminants. It is important to identify these hazards and remove or minimize the risks they present.

Employees who identify a hazard in the workplace should inform their supervisor. Their supervisor then has the primary responsibility for investigating the hazard with input from his or her Dean, Director, Chair, and other staff. All employee injuries require the completion of a Workplace Hazard investigation in addition to the report to Workers' Compensation. Damaged equipment or other workplace property may warrant a hazard investigation at the supervisor's discretion.

A Near Miss is an unplanned event that did not result in injury, illness, or damage – but had the potential to do so.

Call Environmental Health & Safety at 239-590-1414 if you have any questions about this form, or for assistance in completing your Near Miss Investigation Report. Use this form to submit a report of your investigation to Environmental Health & Safety.

Location of the Hazard: *

Date Hazard was Identified: *

Check all appropriate conditions: *

Unsafe equipment Unsafe use of equipment Unsafe condition Unsafe act

Time Identified: *

: Hour Minutes AM/PM Option

Describe the near miss condition; any injuries and any property damage caused or likely. *

You can resize the text box above to show all text if you want to print this page. (Resize arrows appear as you hover in the bottom right corner. Drag to fit.)

Describe any contributing factors of the near miss condition. *

You can resize the text box above to show all text if you want to print this page. (Resize arrows appear as you hover in the bottom right corner. Drag to fit.)

List the actions recommended or implemented to remove the hazard(s) identified/near miss condition. *

You can resize the text box above to show all text if you want to print this page. (Resize arrows appear as you hover in the bottom right corner. Drag to fit.)

Supervisor's Name: *

First Name Last Name

Supervisor's Phone:

Area Code Phone # (digits only)

Supervisor's Email: *

example@fgcu.edu

Department:

Contact Name: *

First Name Last Name

Contact Phone Number: *

Area Code Phone # (digits only)

Contact Email:

example@fgcu.edu

Department: