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| Incident Details (STEP) | | |
| Date of Near Miss (DATE) | | |
| Time of Near Miss (DATE) | | |
| Specific Area/Workstation (LOCATION) | | |
| Brief Summary of Event (TEXT) | | |
| Estimated Speed (if applicable) (NUMBER) | | |
| Severity Level (Potential Harm) (SELECTION options: Minor (First Aid), Moderate (Medical Treatment), Serious (Hospitalization), Critical (Life-Threatening)) | | |
| Reported By (Role) (SELECTION options: Operator, Supervisor, Maintenance, Engineer, Other) | | |
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| Location & Equipment Involved (STEP) | | |
| Specific Location of Near Miss (LOCATION) | | |
| Work Area/Department (TEXT) | | |
| Type of Equipment Involved (SELECTION options: Machine (Specify in Description), Tool, Vehicle (Forklift, Crane), Material Handling Equipment, None, Other (Specify)) | | |
| Equipment ID/Number (if applicable) (TEXT) | | |
| Detailed Description of Equipment Involved (Condition, Last Inspection) (TEXT) | | |
| Equipment Serial Number (if applicable) (NUMBER) | | |
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| People Involved (STEP) | | |
| Number of Employees Potentially Affected (NUMBER) | | |
| Name of Reporter (TEXT) | | |
| Job Title of Reporter (TEXT) | | |
| Witness Statements (if any) (TEXT) | | |
| Departments Involved (SELECTION options: Production, Maintenance, Quality Control, Engineering, Safety, Other) | | |
| Name(s) of Individuals Directly Involved (if known) (TEXT) | | |
| Job Titles of Individuals Directly Involved (if known) (TEXT) | | |
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| Description of Event (STEP) | | |
| Describe the sequence of events leading up to the near miss. Be as detailed as possible. (TEXT) | | |
| What actions were being performed by involved personnel at the time? (TEXT) | | |
| Specify the exact location where the near miss occurred (e.g., machine number, work station). (LOCATION) | | |
| What time did the near miss occur? (DATE) | | |
| If equipment was involved, estimate the speed or operating parameter that contributed (e.g., RPM, pressure, temperature). (NUMBER) | | |
| Describe any unusual sounds, smells, or visual observations preceding the near miss. (TEXT) | | |
| Was there a deviation from standard operating procedures? (SELECTION options: Yes, No, Unknown) | | |
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| Contributing Factors (STEP) | | |
| Was a procedure/work instruction not followed? (SELECTION options: Yes, No, Unknown) | | |
| Was training adequate for the task? (SELECTION options: Yes, No, Not Applicable, Unsure) | | |
| Describe any communication breakdowns that may have contributed to the near miss. (TEXT) | | |
| Estimated Speed (if applicable, e.g., forklift speed in mph/kph) (NUMBER) | | |
| Were environmental factors a contributing factor (e.g., lighting, noise, visibility)? (SELECTION options: Lighting, Noise, Visibility, Housekeeping, Other, None) | | |
| Describe any equipment malfunctions or maintenance issues that may have played a role. (TEXT) | | |
| Was there a time pressure or deadline that may have influenced behavior? (SELECTION options: Yes, No, Unsure) | | |
| Any other factors you believe contributed to the near miss? (TEXT) | | |
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| Potential Consequences (STEP) | | |
| Describe the potential injury or damage that could have occurred. (TEXT) | | |
| Estimated cost of potential damage (if applicable, in USD) (NUMBER) | | |
| Which of the following potential consequences were considered? (SELECTION options: Minor Injury (e.g., cuts, bruises), Serious Injury (e.g., broken bones, concussion), Fatality, Equipment Damage, Production Delay, Environmental Release, Damage to Property, Other (Please specify in LONG_TEXT)) | | |
| If 'Other' was selected above, please describe the potential consequence. (TEXT) | | |
| Severity Rating (Based on potential impact) (SELECTION options: Low, Medium, High) | | |
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| Corrective Actions Proposed (STEP) | | |
| Detailed Description of Proposed Corrective Action (TEXT) | | |
| Estimated Cost of Corrective Action (USD) (NUMBER) | | |
| Action Priority Level (SELECTION options: High, Medium, Low) | | |
| Target Completion Date (DATE) | | |
| Responsible Department(s) (SELECTION options: Maintenance, Engineering, Production, Safety, Quality) | | |
| Corrective Action Type (SELECTION options: Training, Procedure Change, Equipment Modification, Engineering Control, Administrative Control) | | |
| Rationale for Chosen Action (TEXT) | | |
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| Reporting & Verification (STEP) | | |
| Reporter Name (TEXT) | | |
| Date of Report (DATE) | | |
| Time of Report (DATE) | | |
| Department of Reporter (SELECTION options: Production, Maintenance, Quality Control, Engineering, Safety, Other) | | |
| Report Status (SELECTION options: New, Under Review, Resolved, Closed) | | |
| Reviewer Name (if applicable) (TEXT) | | |
| Date of Review (if applicable) (DATE) | | |
| Reviewer Comments (if applicable) (TEXT) | | |
| Verification Method (SELECTION options: Direct Observation, Review of Documentation, Interview, Other) | | |
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