General • Inspections

Hazard/Near Miss Report/H&S Concern Form

Use this form to report hazards, near misses, or health and safety concerns. Your report will help prevent incidents and maintain a safe workplace.

Big Country Raw

09/21/2026

Hazard/Near Miss Report/H&S Concern Form

This procedure is used to formally document and communicate workplace hazards or near miss incidents to supervisors before any injury or accident occurs. It includes sections for employee information, incident details, corrective actions, and required signatures.

Employee Information

Enter Employee(s) Name

Enter Date of Report

Incident Details

Enter Location of Hazard

Select Hazard Class (select A, B or C)

A - Major (high risk-severe consequences such as death, permanent disability, major structural destruction, combined with high probability or frequency of occurrence and also includes major legal non-compliance. Immediate action or strict engineering controls are required.)
B - Moderate (medium risk- moderate injuries or damage such as reversible health effects, chemical burns, sprains, or localized property damage -that require medical treatment or limited time away from work paired with moderate chance of happening. Controls and monitoring are needed)
C - Minor (low risk-minor incidents such as small cuts, requiring only first aid, slight irritation, short term discomfort, or negligible physical /health threats-with a low probability of causing real harm. Standard precaustions are usually enough.)

Describe What Happened (include as much detail as possible, attach pictures, include weights, conditions, etc)

Identify Root Causes (look for system failures, identify unsafe acts and conditions, personal factors and job factors)

Corrective Actions

Supervisor/Manager’s Report of ACTION taken to correct the hazard

Add or drag pictures

Signatures

Signature of Person(s) reporting

Click here to sign

Signature of Department Manager/Supervisor