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? CONCERN HEALTH AND SAFETY CONCERN/NEAR MISS INCIDENT FORM ? NEAR MISS Instructions are on the reverse side. Worker s Name: Worker s Union Affiliation: DATE this form was submitted to the Supervisor:.

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I will use my knowledge, awareness and attitude to make me a safe employee. I will properly use personal protective equipment, procedures, equipment and materials to ensure my safety. I will ensure my environment, building and job site are prepared and maintained to ensure my co-workers and I are safe.

How to Write a Safety Incident Report Worker Characteristics. Injury / Illness Characteristics. Description and Sequencing of Events. Time factors and working conditions. Description of task(s) being performed when the. ... Characteristics of any equipment associated with the. ... Supervision information. Causal factors.

Safety First: How to Report a Safety Concern Step 1: Clearly Identify the Problem or Concern (Preferably in Writing) ... Step 2: Research the Issue to Ensure It Is a Valid Concern. ... Step 3: Report the Concern to Your Supervisor: Be Careful to Follow the Chain of Command.

How Employees Can Effectively Report Safety Concerns Research Before Complaining. ... Follow the Chain of Command. ... Seek Out Allies. ... Be Proactive and Cooperative. ... Know Your Rights. ... Carry Out Risk Assessments. ... Implement a Health and Safety Policy. ... Ensure Open Communication.

A Safety Concern is defined as any condition, practice, or violation that causes a substantial probability of physical harm, property loss, and/or environmental impact such as: Loose railing on a stairwell. Tripping hazards. Anything you feel has the potential to cause harm to people, property, or the environment.

A Safety Concern is defined as any condition, practice, or violation that causes a substantial probability of physical harm, property loss, and/or environmental impact such as: Loose railing on a stairwell. Tripping hazards. Anything you feel has the potential to cause harm to people, property, or the environment.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232