Please enable JavaScript in your browser to complete this form. APA/AIE Good Catch/ 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. A Good Catch is to take a proactive approach to identify and address potentially harmful events. To recognized an unsafe condition, action, defect or flawed piece of equipment and act to prevent an event from occurring. It’s caught early and prevented something unfortunate from happening. 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 MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Time of Day Type of Work Type of Work Regular Job Assignment Trouble Call/After Hours Call-in Over Time After Shift Job Description What was the job being performedDrivingSubstation switchingMaterial handlingMeter workOffice incidentOHD construction/maintenance OHD restoration/repairPublic liabilityRight of way maintenance Substation work URD construction/maintenanceURD restoration/repairMechanic shopTransformer shopLOTO electrical LOTO power plant 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 Field Office Warehouse Yard Maintainence Shop Power plant Member’s property Vehicle/Equipment in use Bucket Derrick Flat Bed Pickup/Service Heavy Equipment ROW Equipment Common Vehicle Other If other, or equipment, please describe below Cause of Incident Equipment Failure Human Error Work Practice/Procedure Weather Fire Member/Public Pole/Line/Material Failure Animal/insect House Keeping Unkown Lack of Maintenance 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 else was learned that can be shared to help others keep something similar from happening? 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. Comment Submit