Near Miss Reporting
form

Employee Name: Contact Number(optional): Email:

Name (optional): Age (optional):

Company: Select CHEC CRCC JCD MBL SAMA Visitor/Client if Other(type...) Position: Select Carpenter Engineer Flagman Foreman Labour Office Employee Operator if Other(type...)

Location: Select Opera House SPMI Modular Office Zahran Office Contractor Parking Area MUPR Logistic Area Oceanarium Stadium Headquarter (HQ) if Other(type...) Specific Location (If Applicable):

Date of Near Miss: Time of Occurrence:

Site/Office: Select Site Office Activity/Discipline:

Description: Select A cabinet drawer being left open and causing someone to trip and fall Loose clothing catching on a foot during a hurried walk, but a reflex helped regain balance Laying a cable across a hallway nearly causing someone to trip A wet surface almost causing someone to slip An employee reaching for a high shelf nearly falling when the chair moved Instructions to "fill in custom field" if there are any other incidents to report if Other(type...) Select A potential electrical fire almost started due to overloaded circuits or faulty wiring Laying cable across the access nearly caused someone to trip Failing to follow lockout/tagout procedures narrowly avoided potential electrocution hazards Damaged or improperly insulated electrical cables caused electrocution Performing electrical work near a water source almost led to electrocution if Other(type...) Back to Options

Corrective Action: Select Job suspended and access was restricted until proper safety measures are implemented The workplace environment was adjusted to minimize the risk of similar incidents Communication and awareness sessions were enhanced to reduce the potential hazards Lessons learned from the near miss were incorporated into existing procedures to prevent future occurrences if Other(type...) Select Job suspended and access was restricted until proper safety measures are implemented Review of risk assessment for the high risk activities Update signage and safety warnings in the area Ensure workers are using the appropriate PPE for the task at hand and that the PPE is properly maintained and in good c Using lifting equipment for heavy materials instead of manual lifting Providing proper ventilation for dust or fumes Restrict access to specific areas until proper safety measures are implemented Installing guardrails around excavations Utilizing fall arrest systems Safety supervisor was called and made aware of the near miss if Other(type...) Back to Options

Name: Date: