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    Near Miss Blank Form

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    Caminito Mallorca
    This near-miss report form allows users to document and report potential safety hazards, unsafe conditions or acts, or safety suggestions. It collects key details about the incident such as the date, location, type of concern, a description of the potential hazard and possible outcomes, as well as optional contact information and safety suggestions from the reporter. Completed forms should be uploaded to a shared folder and emailed to the specified safety contact.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Near Miss Blank Form

    Uploaded by

    Caminito Mallorca
    436 views1 page
    This near-miss report form allows users to document and report potential safety hazards, unsafe conditions or acts, or safety suggestions. It collects key details about the incident such as the date, location, type of concern, a description of the potential hazard and possible outcomes, as well as optional contact information and safety suggestions from the reporter. Completed forms should be uploaded to a shared folder and emailed to the specified safety contact.

    Original Description:

    Template for reporting of near miss

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    This near-miss report form allows users to document and report potential safety hazards, unsafe conditions or acts, or safety suggestions. It collects key details about the incident such as the date, location, type of concern, a description of the potential hazard and possible outcomes, as well as optional contact information and safety suggestions from the reporter. Completed forms should be uploaded to a shared folder and emailed to the specified safety contact.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    436 views1 page

    Near Miss Blank Form

    Uploaded by

    Caminito Mallorca
    This near-miss report form allows users to document and report potential safety hazards, unsafe conditions or acts, or safety suggestions. It collects key details about the incident such as the date, location, type of concern, a description of the potential hazard and possible outcomes, as well as optional contact information and safety suggestions from the reporter. Completed forms should be uploaded to a shared folder and emailed to the specified safety contact.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    Near-Miss Report Form

    A near-miss is a potential hazard or incident that has not resulted in any personal injury or
    property damage. Some examples of near-misses are unsafe conditions, improper use of
    equipment, use of faulty equipment, not following proper procedures…. It is everyone’s
    responsibility to report and correct any of these potential hazards immediately. Please use this
    form to report near-misses and assist us in preventing future incidents and making UCD a safer
    workplace.

    School Building: Room #:


    Chemical & Bioprocess Engineering
    Date of Incident: Time of Incident:

    Mark all appropriate conditions: Type of concern:


    o Near-miss o Unsafe act
    o Safety concern o Unsafe condition of area
    o Safety suggestion o Unsafe condition of equipment
    o Other (describe): o Unsafe use of equipment
    o Other (describe):

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

    Safety Suggestions:

    Name (Optional): Date Reported:

    Phone Number (Optional): Email Address (Optional):

    Please upload form to appropriate folder on Google Drive.


    E-mail a copy to: damian.mooney@ucd.ie
    For questions/cases deemed immediately dangerous to life or death, call SIRC at 01-716

    8768/8771. In emergency call 999.

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