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)EmployeeContractorMember of the publicDate and TimeDate of Incident MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Time of DayType of WorkType of WorkRegular Job AssignmentTrouble Call/After Hours Call-inOver Time After ShiftJob DescriptionWhat 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 plantNumber of crew members at job site (including yourself)Number of possible injury/injuries (including yourself)Number of hours worked since last rest period or shiftLogistical InformationLocationFieldOfficeWarehouseYardMaintainence ShopPower plantMember's propertyVehicle/Equipment in useBucketDerrickFlat BedPickup/ServiceHeavy EquipmentROW EquipmentCommon VehicleOtherIf other, or equipment, please describe belowCause of Incident Equipment FailureHuman ErrorWork Practice/ProcedureWeatherFireMember/PublicPole/Line/Material FailureAnimal/insectHouse KeepingUnkownLack of Maintenance Please provide a summary of the incident Other informationWas appropriate safety equipment provided at the job site?YesNoWas the safety equipment in use at the time?YesNoWas there a job briefing prior to work?YesNoWas a job briefing conducted following this near miss or incident?YesNoDid the individual reporting the near miss understand their role?YesNo (If no, please explain below)Is there a safety policy or procedure for this particular job?YesNoWhat 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?YesNoWhat 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?YesNoIt is recommended that employees are informed of steps taken to avoid repeating the near miss situation. MessageSubmit