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Near Miss Report - Detroit

Near Miss Report

1. Initial Information

Date of Good Catch/Near Miss? (MM/DD/YYYY) *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

What time did this Good Catch/Near Miss occur? *This question is required.

Reporting Company? *This question is required.

Contract Company: *This question is required.

Department? *This question is required.

Operations *This question is required.

Maintenance *This question is required.

Product Control *This question is required.

Reporting Company Name?

Did this situation have a high potential of causing a fatality, hospitalization or life altering * event ?

*( significant changes to a person's life such as head injury/ amputation/ serious burns / disablement / catastrophic fracture ) *This question is required.

2. Location

Location of Near-Miss *This question is required.

Work Type *This question is required.

3. Was Stop Work Authority used? *This question is required.

4. Description & Corrective Actions *This question is required.

In a few sentences please describe what happened (who/what /where/ etc ) *This question is required.

Corrective Actions taken or suggestions for prevention of Near Miss? *This question is required.

Follow-Up

Would you like someone to follow up with you? *This question is required.

Your Name:

Best way to contact you? *This question is required.

Phone Number *This question is required.

Email: *This question is required.