Workplace Near Miss Report
Workplace Near Miss Report
Please complete all sections of this form.
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Incident Information |
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Date and Time: |
[Month Day, Year] / [Time] |
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Location of the Incident: |
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Description of the Near Miss: |
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Employee Information |
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Employee(s) Involved: |
[Name] |
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Job Title(s): |
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Department: |
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Supervisor’s Name: |
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Witness Information |
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Name of Witness(es): |
[Name] |
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Contact Information: |
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Witness Statement(s): |
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Immediate Actions Taken |
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The area was immediately cleared of the obstruction, and additional signage was put up to signal the pedestrian walkway more clearly. The forklift driver was reminded of the importance of maintaining clear lines of sight. |
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Investigation and Recommendations |
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Initial Assessment: |
The primary cause was identified as inadequate signaling of pedestrian pathways in the warehouse. |
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Recommendations: |
Implement periodic checks to ensure pathways are clear and properly marked. Consider additional training for forklift operators on navigating busy areas. |
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Assigned Responsibility: |
The warehouse supervisor is responsible for implementing these corrective actions. |
Prepared by:
[Your Name]
[Job Title]
[Month Day, Year]
