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Near Miss
Near-misses are an unplanned event that did not result in injury, illness, or damage—but had the potential to do so. Somewhere in the chain of events leading to the near miss, we caught a lucky break.
Good Catch
A “good-catch” is when an employee recognizes an unsafe condition, action, or defect and actively takes measures to prevent an event from occurring.
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Observations-Office
Near Miss
Good Catch
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Observation-Field
Observer Name (not required)
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District
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Date
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Observed-Dept. or Org
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Task/Job Observed
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Location of Observation
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Please skip the item or section if it is not applicable to the task/job that is included in the observation. A skipped question is considered NA.
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PPE
Hi-Visibility Clothing
Safe
At-Risk
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Eyes/Face
Safe
At-Risk
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Hardhat
Safe
At-Risk
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Hand (gloves adequate)
Safe
At-Risk
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Footwear
Safe
At-Risk
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Hearing Protection
Safe
At-Risk
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Respiratory
Safe
At-Risk
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Fall Protection
Safe
At-Risk
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Comments
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Body Position
Lifting/Pushing/Pulling
Safe
At-Risk
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Awkward/Twisting/Bending
Safe
At-Risk
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Paying Attention
Safe
At-Risk
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Pinch Point
Safe
At-Risk
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3 Points of Contact
Safe
At-Risk
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Struck by Potential
Safe
At-Risk
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Pace
Safe
At-Risk
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Comments
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Tools & Equipment
Correct Tool/Equipment
Safe
At-Risk
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Used Correctly
Safe
At-Risk
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Condition of Tool/Equipment
Safe
At-Risk
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Comments
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Housekeeping
Slip/Trip/Fall Hazards
Safe
At-Risk
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Clear Floor/Exits
Safe
At-Risk
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Lighting
Safe
At-Risk
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Comments
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Vehicular Operations
Walk Around/Circle Check
Safe
At-Risk
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Seatbelt
Safe
At-Risk
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Stability & Terrain (rollover hazard)
Safe
At-Risk
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Attachments
Safe
At-Risk
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Overhead Hazards
Safe
At-Risk
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Backing/Spotting
Safe
At-Risk
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Vehicle Visibility/Parking Location
Safe
At-Risk
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Comments
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Noted Safe Behaviors
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Reasons Behind At-Risk Behaviors
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Solutions Proposed/Implemented
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Attach a photo or video. (not required)
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