MOD-PAC Near Miss Reporting Form

A near miss is defined as an unplanned event that did not result in injury, illness, or damage - but had the potential to do so. Only a fortunate break in the chain of events prevented an injury, fatality or damage. Report any near misses using this form so that the potential risk for an accident can be reviewed and eliminated.

Date near miss occured

Person who saw the near miss occur

Person filling out this form

Describe the near miss using as much detail as possible

What could have happened if the near miss resulted in injury or damage.

What action was taken after the near miss to correct the sitution

If possible describe why the near miss occured

Upload any pictures or files that help in reporting the near miss

Drag and drop files here or
Privacy Notice|Report Abuse