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NEAR MISS REPORT

Near-Accident, that is, situations where you survived without injury or accident; By filling out this form, throw it into the boxes in the available places.

Fill out this form and report the DANGEROUS situation/behavior that you see anywhere in the company and that you think needs urgent action, to your Department Officer IMMEDIATELY.

Near Accident/Danger;

Date

Time

Place

Endangered(s)

Current Task

Explain the Near Miss/hazard.

What is the precaution to be taken, what do you recommend?

Select the type of unsafe behavior and/or condition that caused the Near Miss/danger.

Unsafe Behaviors

Work without authorization Giving/receiving a false warning Error in safety Improper speed Not using the safety device Not using personal protective materials Equipment usage error Using defective equipment Working in a field/machine that he has no knowledge of Disobeying instructions Fatigue/insomnia Morale/fear/difficulty Working without discipline/not taking it seriously

Unsafe Conditions

Insufficient machine/equipment containment Insufficient personal protective equipment Defective equipment/machine Inadequate warning system Fire danger Wind Explosion hazard Unsafe stacking Unclosed gaps Unsafe, incorrect lifting Fault in electrical systems Irregular environment Excessive noise Slippery ground Insufficient lighting

Formu Dolduranın

Name

Surname

Department

Mission

Notification date