Near Miss Reporting Checklist
Download our Near Miss Reporting Checklist to boost safety and work productivity. Streamline your incident tracking and automate workflows with ChecklistGuro.
Found this Media helpful?
Comments
There are no comments yet. Be the first to add one!
Related Media Files
| Label | Value | Notes |
|---|---|---|
| Created by checklistguro.com | ||
| Pre-Shift Planning & Hazard Assessment (STEP) | ||
| Date of Assessment (DATE) | ||
| Time of Assessment Start (DATE) | ||
| Brief Description of Task/Job to be Performed (TEXT) | ||
| Potential Hazards Identified (Initial Assessment) (TEXT) | ||
| Hazards Related to Previous Incidents/Near Misses? (SELECTION options: Yes, No, Unknown) | ||
| Previous Control Measures (if any) & Their Effectiveness (TEXT) | ||
| Risk Level (Based on Initial Assessment) (SELECTION options: Low, Medium, High) | ||
| Name of Person Performing Hazard Assessment (TEXT) | ||
| Signature of Person Performing Hazard Assessment (SIGNATURE) | ||
| Identify Energy Sources (STEP) | ||
| What types of energy are present? (SELECTION options: Electrical, Pneumatic, Hydraulic, Mechanical (e.g., rotating shafts), Thermal (e.g., steam, hot oil), Chemical (e.g., pressurized vessels), Gravitational (e.g., elevated loads), None) | ||
| Describe any unusual or non-standard energy sources. (TEXT) | ||
| Voltage of electrical supply (if applicable) (NUMBER) | ||
| Pressure of pneumatic/hydraulic systems (if applicable) (NUMBER) | ||
| Identify the primary energy source requiring isolation. (SELECTION options: Electrical, Pneumatic, Hydraulic, Mechanical, Thermal, Chemical) | ||
| Additional Notes about Energy Sources (e.g., secondary hazards) (TEXT) | ||
| Isolation & Shutdown Procedures (STEP) | ||
| Detailed Step-by-Step Shutdown Procedure (TEXT) | ||
| Equipment ID Number (NUMBER) | ||
| Shutdown Sequence (e.g., Normal Stop, Emergency Stop) (SELECTION options: Normal Stop, Emergency Stop, Controlled Shutdown) | ||
| Location of Primary Isolation Point (LOCATION) | ||
| Date of Procedure Review/Update (Last Reviewed) (DATE) | ||
| Time of Shutdown Initiation (DATE) | ||
| Any Unusual Considerations for Shutdown? (TEXT) | ||
| Lockout/Tagout Application (STEP) | ||
| Lock Type Used (e.g., Keyed, Combination) (SELECTION options: Keyed Lock, Combination Lock, Other (Specify in LONG_TEXT)) | ||
| Lock ID Number (NUMBER) | ||
| Tag Type Used (SELECTION options: Standard Tag, Custom Tag, Blank Tag (To be filled)) | ||
| Tag ID Number (NUMBER) | ||
| Tag Information (TEXT) | ||
| Lock/Tag Location (Specific Point of Isolation) (LOCATION) | ||
| Authorized Personnel Applying LOTO (SELECTION options: Single Authorized Person, Multiple Authorized Persons, Group Lockout Procedure) | ||
| Authorized Personnel Signature (Lock Application) (SIGNATURE) | ||
| Verification of Isolation (STEP) | ||
| Voltage Reading (Phase-to-Phase) (NUMBER) | ||
| Voltage Reading (Phase-to-Neutral) (NUMBER) | ||
| Current Reading (Amps) (NUMBER) | ||
| Confirm Zero Energy State? (SELECTION options: Yes, No) | ||
| Describe Verification Steps Taken (TEXT) | ||
| Sound Check (Confirm no equipment noise) (SELECTION options: Yes, No) | ||
| Movement Check (Confirm no unintended movement) (SELECTION options: Yes, No) | ||
| Verification Date (DATE) | ||
| Verification Time (DATE) | ||
| Work Performance & Observation (STEP) | ||
| Describe the work being performed on the equipment. (TEXT) | ||
| Number of personnel working on the equipment. (NUMBER) | ||
| Are there any unusual noises or movements observed? (SELECTION options: Yes, No) | ||
| If yes, describe the unusual noises or movements. (TEXT) | ||
| Were any tools or equipment accidentally moved or dropped during the work? (SELECTION options: Yes, No) | ||
| If yes, describe the incident and corrective actions taken. (TEXT) | ||
| Is anyone experiencing discomfort or noticing anything concerning? (SELECTION options: Yes, No) | ||
| If yes, describe the discomfort or concern. (TEXT) | ||
| Removal of LOTO & Equipment Restart (STEP) | ||
| Date of LOTO Removal (DATE) | ||
| Time of LOTO Removal (DATE) | ||
| Reason for LOTO Removal (SELECTION options: Completion of Work, Shift Change, Equipment Malfunction, Other (Specify)) | ||
| If 'Other' selected, please explain reason for removal (TEXT) | ||
| Was a visual inspection performed? (SELECTION options: Yes, No) | ||
| Equipment Voltage/Pressure after Verification (NUMBER) | ||
| Confirmation of Clear Communication with Affected Personnel (SELECTION options: Yes, No) | ||
| Authorized Personnel Signature (Removal) (SIGNATURE) | ||
| Name (Printed) of Authorized Personnel (TEXT) | ||
| Documentation & Sign-off (STEP) | ||
| Date of LOTO Procedure (DATE) | ||
| Time of LOTO Implementation (DATE) | ||
| Equipment/Machine ID (NUMBER) | ||
| Brief Description of Work Performed (TEXT) | ||
| LOTO Procedure Followed (Reference) (SELECTION options: Standard Procedure A, Standard Procedure B, Custom Procedure - Specify in Notes) | ||
| Additional Notes/Observations (TEXT) | ||
| Authorized Lockout Person Signature (SIGNATURE) | ||
| Affected Employee Acknowledgement (SIGNATURE) |
