NEAR MISS REPORTING CHECKLIST

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--- INCIDENT DETAILS ---
[ ] Date of Near Miss
[ ] Time of Near Miss
[ ] Specific Area/Workstation
[ ] Brief Summary of Event
[ ] Estimated Speed (if applicable)
[ ] Severity Level (Potential Harm) (Minor (First Aid), Moderate (Medical Treatment), Serious (Hospitalization), Critical (Life-Threatening))
[ ] Reported By (Role) (Operator, Supervisor, Maintenance, Engineer, Other)

--- LOCATION & EQUIPMENT INVOLVED ---
[ ] Specific Location of Near Miss
[ ] Work Area/Department
[ ] Type of Equipment Involved (Machine (Specify in Description), Tool, Vehicle (Forklift, Crane), Material Handling Equipment, None, Other (Specify))
[ ] Equipment ID/Number (if applicable)
[ ] Detailed Description of Equipment Involved (Condition, Last Inspection)
[ ] Equipment Serial Number (if applicable)

--- PEOPLE INVOLVED ---
[ ] Number of Employees Potentially Affected
[ ] Name of Reporter
[ ] Job Title of Reporter
[ ] Witness Statements (if any)
[ ] Departments Involved (Production, Maintenance, Quality Control, Engineering, Safety, Other)
[ ] Name(s) of Individuals Directly Involved (if known)
[ ] Job Titles of Individuals Directly Involved (if known)

--- DESCRIPTION OF EVENT ---
[ ] Describe the sequence of events leading up to the near miss. Be as detailed as possible.
[ ] What actions were being performed by involved personnel at the time?
[ ] Specify the exact location where the near miss occurred (e.g., machine number, work station).
[ ] What time did the near miss occur?
[ ] If equipment was involved, estimate the speed or operating parameter that contributed (e.g., RPM, pressure, temperature).
[ ] Describe any unusual sounds, smells, or visual observations preceding the near miss.
[ ] Was there a deviation from standard operating procedures? (Yes, No, Unknown)

--- CONTRIBUTING FACTORS ---
[ ] Was a procedure/work instruction not followed? (Yes, No, Unknown)
[ ] Was training adequate for the task? (Yes, No, Not Applicable, Unsure)
[ ] Describe any communication breakdowns that may have contributed to the near miss.
[ ] Estimated Speed (if applicable, e.g., forklift speed in mph/kph)
[ ] Were environmental factors a contributing factor (e.g., lighting, noise, visibility)? (Lighting, Noise, Visibility, Housekeeping, Other, None)
[ ] Describe any equipment malfunctions or maintenance issues that may have played a role.
[ ] Was there a time pressure or deadline that may have influenced behavior? (Yes, No, Unsure)
[ ] Any other factors you believe contributed to the near miss?

--- POTENTIAL CONSEQUENCES ---
[ ] Describe the potential injury or damage that could have occurred.
[ ] Estimated cost of potential damage (if applicable, in USD)
[ ] Which of the following potential consequences were considered? (Minor Injury (e.g., cuts, bruises), Serious Injury (e.g., broken bones, concussion), Fatality, Equipment Damage, Production Delay, Environmental Release, Damage to Property, Other (Please specify in LONG_TEXT))
[ ] If 'Other' was selected above, please describe the potential consequence.
[ ] Severity Rating (Based on potential impact) (Low, Medium, High)

--- CORRECTIVE ACTIONS PROPOSED ---
[ ] Detailed Description of Proposed Corrective Action
[ ] Estimated Cost of Corrective Action (USD)
[ ] Action Priority Level (High, Medium, Low)
[ ] Target Completion Date
[ ] Responsible Department(s) (Maintenance, Engineering, Production, Safety, Quality)
[ ] Corrective Action Type (Training, Procedure Change, Equipment Modification, Engineering Control, Administrative Control)
[ ] Rationale for Chosen Action

--- REPORTING & VERIFICATION ---
[ ] Reporter Name
[ ] Date of Report
[ ] Time of Report
[ ] Department of Reporter (Production, Maintenance, Quality Control, Engineering, Safety, Other)
[ ] Report Status (New, Under Review, Resolved, Closed)
[ ] Reviewer Name (if applicable)
[ ] Date of Review (if applicable)
[ ] Reviewer Comments (if applicable)
[ ] Verification Method (Direct Observation, Review of Documentation, Interview, Other)

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