SUPERVISOR NEAR-MISS INVESTIGATION REPORT

Supervisor of Employee Involved Budget Unit Name Date Reported

PLANT MANAGEMENT
1.Name of Employee Involved 2.Employees usual occupation 3.Date of Near-Miss

4.Occupation at time of accident

5.Length of employment Less than 1 mo. 6 mo.-5 yrs. 8.Time of Near-Miss a.m. p.m. A. B. Time within shift 1-5 mo. more than 5 yrs.

6.Time in occupation at time of accident Less than 1 mo. 1-5 mos.

7.Employment category Regular, full-time Temporary Regular, part-time Seasonal Working overtime Other Non-Employee

6 mos.-5 yrs. more than 5 yrs. 9. Phase of employees workday at time of injury During rest period During meal period

Entering or leaving work Performing work duties C. Type of shift 10. Describe the near-miss: Description of Event: What was employee doing just before and at the time of the near-miss?

__________________________________________________________________________________________________________________________

What happened or what work conditions contributed to the near miss (e.g., Object/Equipment/Substance )

11. Nature and Extent of Potential Property Damage:

FORM RM/NM 211

12. Task and Activity at Time of Near-Miss General type of task:_________________________________________________ Specific activity:_____________________________________________________ Employee was working: Alone With crew or fellow worker Other: specify

13. Posture of employee

14. Supervision at time of accident Directly supervised Not supervised Indirectly supervised Supervision not feasible

15. Factors that contributed to near-miss Please check all that apply Hazard Not recognized/identified Identified, but not addressed Inadequate repair Communication Breakdown in verbal communication Breakdown in written communication Confusion after communication Other Facilities/Equipment Personal protective equipment (see below) Faulty equipment Poor/inadequate maintenance Inappropriate use Missing guards Obsolete/antiquated Inadequate design Ergonomic factors Equipment failure Trip hazard Slip hazard Struck by Other PPE Requirements Req. Used Eye Face Hearing Skin/Glove Foot Other Type

Work Procedures None developed Not followed Partially followed Not understood Not appropriate Not communicated Other Training & Certification Insufficient training Circumstances not covered Ineffective training Worker not authorized Outdated Training

Other Weather/temperature Extended work hours Worker fatigue Physical overexertion Work in elevated area Chemical Use Biological agent Radiation Electricity Mechanical Animals

Additional Comments:

FORM RM/NM 211