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> near miss box checklist
near miss box checklist
Incident Details
Date of near miss
Time of near miss
Location of near miss
Description of near miss
Witness Information
Name of witness
Contact information of witness
Statement from witness
Potential Hazards
Identify potential hazards that contributed to near miss
Evaluate severity of potential hazards
Determine likelihood of potential hazards causing harm
Corrective Actions
Implement immediate corrective actions
Develop long-term corrective actions
Assign responsibility for corrective actions
Follow-Up
Schedule follow-up to ensure corrective actions are implemented
Review effectiveness of corrective actions
Update near miss box log with findings
Additional Comments
Any additional information or comments
Recommendations for preventing similar incidents in the future
Review and Sign-Off
Review checklist for completeness and accuracy
Sign and date checklist to indicate completion
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