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NEAR MISS REPORT

Investigation Report

DATE

Time

# of Pages (including cover)

ATTENTION

Heidi Rodriguez

FAX #

916.568.0269

COMPANY

DPR Construction

REFERENCE

FROM

REGION

Near Miss Incident Report

Incident Reporting Instructions

1. Ensure the safety and security of the job site.

2. Substance abuse screening should be completed for each individual involved and anyone who could have contributed to the near miss incident.

3. Contact your regional Safety Manager immediately

4. Complete the Near Miss Reportpacket thoroughly. Fax the completed documents to Heidi Rodriguez at 916.568.0269 by end of business the day of the incident

REQUIRED DOCUMENTS
Near Miss Incident Report
Pre-task Plan
Corrective Actions
Verification of Substance Abuse Screen(s)

Project Information:

Project/Project#: proyecto: *

Date: fecha: *

Project Type: proyecto: *

Completed By: *

Incident Information:

Date of incident:

Time of incident:

Trade:

Project phase:

Incident key word(s):

General activity at time of incident:

Incident Severity:

Company:

Near Miss Information:

Facilitator Name:

Date:

Superintendent

Safety Professional

Foreman

Involved Worker

Project Manager

Sub Foreman

Safety Coordinator

Sub Superintendent

Other

Description of Incident:

Severity Potential:

Complete worksheet below to determine potential impact of incident.

		Score –1	Score –2	Score –3	Score –4	Score –5
A.	Injury Potential	None	No medical assistance	First aid	OSHA recordable	Lost time injury
B.	Potential for area of incident to be occupied	Unlikely	Occasional	Moderate	Likely	Definite
C.	Radius that injury can be expected	1-9 feet	10-25 feet	25-49 feet	50-99 feet	100+ feet
D.	Number of people in area of radius	None	1	2 to 3	4 to 8	9 or more
E.	Chance of escape	100%(Certain)	75%(Likely)	50%(Possible)	25%(Unlikely)	0%(None)

Incident potential= A + B + C + D + E = Total Score=

Near Miss Incident Rating Scale

1 to 7	MINIMAL	Incident is not a near miss but had no potential for injury –depending on incident, identify contributing factors and implement corrective action
8 to 12	MODERATE	Complete attached witness statements, review incident and identify contributing factors and record corrective actions in tables below
13 to 25	SIGNIFICANT	Investigate incident, complete entire Root Cause Analysis, complete witness statements and record corrective actions

Events/Timeline:

(complete this section in detail for Root Cause Analysis, otherwise, skip to Contributing Factors)

Contributing Factors:

Root Cause:

	Corrective Actions	Responsibility	Due Date
1
2
3
4
5
6
7
8