Near Miss Report

This report form is to be completed whenever there is a Near Miss in any area of the facility. A
NEAR MISS is defined as having little if any immediate impact on individuals, processes, or the
environment but provides insight into accidents that could happen and accidents that didn’t
happen due to somebody’s good catch. A good catch may break the cycle in the chain of events
that could lead to a serious event that causes injury or property damage.

This report does not replace the Accident/Incident Report Form, which must still be completed
in the event of an accident or injury to a person in Copan Industries.

The Near Miss Report will be used to implement risk reduction strategies in the facility and to
educate all personnel in safety matters.

Date and time of Near Miss: ________________________________________

Location: ____________________________________________

Person(s) Involved (Name, Title, and Department):

_________________________________________________
____________________________________________________________________________

Witnesses, if any:
____________________________________________________________________________
______________
Describe Near Miss:

____________________________________________________________________________
_________________________________________________________________________

Cause of Near Miss:

________________________________________________________________________
_________________________________________________________________________

Actions Taken to Prevent Incident or Near Miss from Happening Again:

Supervisor or Principal Investigator Notified (Include Date and Time):

Supervisor’s Signature and Date:

_______________________________________________________________________

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*Return Original to EHS Representative