APA/AIE Near Miss or Incident Reporting Form

APA/AIE Near Miss or Incident Reporting Form information - Please read first

This form is meant to collect information on near misses or incidents to start discussions that will raise awareness. A near miss is an unplanned event that did not result in injury, illness, or damage - but had the potential to do so. The form is designed to keep the filer anonymous. You are welcome to add any older event that you think will help others. We encourage you to listen during safety meetings or any other utility interactions/communications for any incidents that count as learning events and could be reported on this form. The information submitted on this form will help all of us learn from each other and aid our safety mission.

Who was involved? (You may check more than one)

Employee
Contractor
Member of the public

Date and Time

Date of Incident //

Time of Day

Type of Work

Regular Job Assignment
Trouble Call/After Hours Call-in
Over Time After Shift

Job Description

What was the job being performed

Number of crew members at job site (including yourself)

Number of possible injury/injuries (including yourself)

Number of hours worked since last rest period or shift

Logistical Information

Location of Near Miss

Vehicle/Equipment in Use

If other, or equipment, please describe below

Cause of Incident

Please provide a summary of the incident

Other information

Was appropriate safety equipment provided at the job site?

Yes
No

Was the safety equipment in use at the time?

Yes
No

Was there a job briefing prior to work?

Yes
No

Was a job briefing conducted following this near miss or incident?

Yes
No

Did the individual reporting the near miss understand their role?

Yes
No (If no, please explain below)

Is there a safety policy or procedure for this particular job?

Yes
No

What is the procedure/what should the policy or procedure be?

In your opinion, if this were an actual incident would it have serious incident or fatality potential?

Yes
No

What has been done to prevent this incident from happening again?

Does the reporting employee and associated employees know what has been done to keep this from happening again?

Yes
No

It is recommended that employees are informed of steps taken to avoid repeating the near miss situation.