Safety Reporting
This form serves as an Incident/Near Miss form and Hazard ID/Suggestion form. Follow prompts accordingly. This ensures critical incident details are captured consistently and completely, leading to more effective investigations and preventative actions.
States Manufacturing
11/13/2025
Safety Reporting
This form serves as an Incident/Near Miss form and Hazard ID/Suggestion form. Follow prompts accordingly. This ensures critical incident details are captured consistently and completely, leading to more effective investigations and preventative actions.
Select most appropriate category
if the answer is "oneOf [Safety Suggestion - General safety improvement idea]"
Write location and problem statement:
Example: "Whole facility; first responders do not have clothing/apparel to be identified"
if the answer is "oneOf [Incident/Near Miss - An event occurred]"
Was anyone injured as a result of the incident?
if the answer is "oneOf [Yes]"
Has team member received the appropriate first-aid and care for injury?
if the answer is "oneOf [Yes, but may require elevated care,No]"
What type of injury occured?
if the answer is "oneOf [Other]"
Describe Injury Type
if the answer is "oneOf [Sprain/Strain,Bruise/Contusion,Burn/Irritation (Thermal/Chemical),Foreign Object in Eye,Cut/Laceration,Other]"
What was the cause of injury?
if the answer is "oneOf [Other]"
Describe Cause of Injury
if the answer is "oneOf [No]"
Which hazard could have resulted from the Near Miss? (Select MOST applicable)
if the answer is "oneOf [Other]"
Describe Type of Hazard Present
Location of incident or near miss
if the answer is "oneOf [Other]"
Write Location of Incident/Near-Miss
Describe the event(s) leading up to the incident:
Why did the incident happen?, What were the actions of team member?, Was it a non-routine task?, etc.
Was employee using required personal protective equipment?
if the answer is "oneOf [Hazard ID - No event, but identified unsafe condition]"
Write Specific Location of Hazard
Department, Area, Equipment, etc.
Write idea to help improve process or prevent hazard from occurring again?
Example: Substituting task with safer method, Workstation redesign, Change in process, PPE Assessment, etc.
Source: States Manufacturing (Community Member)