“NEAR MISS” INVESTIGATION FORM

The following report must be completed for ALL “near miss” incidents.

IDENTIFICATION:

Date of Investigation:_____________________________

JOB INSTRUCTION:

Please answer the following:

	Incident Description:

	What happened?_______________________________________________________________

	_____________________________________________________________________________

	Why did it happen?_____________________________________________________________

	_____________________________________________________________________________

Safety Procedures:

	How can we prevent this from happening again?_______________________________________

	_____________________________________________________________________________

Injury Potential:

	What type of injury could have occurred from this incident?_______________________________

	______________________________________________________________________________