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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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Near Miss
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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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Housekeeping
Slip/Trip/Fall Hazards
Safe
At-Risk
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Storage/Clutter
Safe
At-Risk
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Comments
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Body Position
Lifting/Bending
Safe
At-Risk
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Reaching/Twisting
Safe
At-Risk
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Paying Attention
Safe
At-Risk
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Comments
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Layout/Work Environment
Monitor Position/Glare
Safe
At-Risk
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Mouse & Pad/Keyboard
Safe
At-Risk
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Adequate Lighting
Safe
At-Risk
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Layout (frequently used tools nearby)
Safe
At-Risk
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Comments
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Noted Safe Behaviors/Actions
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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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