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Near Miss Reporting Form

2. Issue/Potential Issue Location:

   1. City Hall
   2. Library
   3. Public Works
   4. Aquatics
   5. Police Department
   6. Airport
   7. Other-Please Specifiy

3. Date/Time of Issue or Potential Issue:*
   Date/Time of Issue or Potential Issue:

   Date/Time of Issue or Potential Issue:

5. Other Location

6. Picture Upload

8. What Happened?

9. What Do You Think Is The Solution To This Problem?

11. Your Name (optional):

13. Near Miss Examples:

    Wrench falls & nearly hits worker’s head. Finding a live wire with sparks. Equipment tip-over while being operated, no injuries. Roll up door descending at uncontrolled rate. Burns to PPE during “hot work”. Clothing caught in machinery parts, no injuries. Failure to use PPE in area of actual exposure. Slip/falls from ice on stairs or landings, no injuries. Insufficient number of lifeguards on duty for number of customers. Children running on pool deck. Horseplay in swimming pool, pool deck or locker room. Inadequate emergency equipment in swimming pool area. Use of a damaged or defective ladder or improper use of equipment in place of a ladder. Operating equipment without authorization or without required training. Operating equipment or vehicles at unsafe speeds. Vehicle response speed too fast for situation. Uncharged or expired fire extinguisher. (T: Safety: Near Miss Policy: Near Miss Blank Jan 2014.doc)

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15. 1. Receive an email copy of this form.
16. Email address

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17. Submit

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