Required fields are marked with asterisks (*)

Near Miss/Hazard Report Form

This form is intended for situations where there is the potential for injury, illness or violent behaviour in the workplace, but where no injury or illness actually occurs.

This form may be completed by any worker for the City of St. Catharines (employees, students and volunteers).

Once this report has been submitted, it will go directly to the Human Resources Health and Safety Consultant.

IF A WORKER HAS BEEN INJURED, DO NOT USE THIS FORM!

Workplace incidents resulting in injury or illness require completion of the Employee Incident Report, regardless of how minor.

Near Miss Details

Date of Incident

Time of Incident

Where did the incident occur

Describe what happened or what was observed

Attach here any photos or additional documents you have. If you have more than 5 files please email the remaining documents to the Health and Safety Consultant.

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

What dangers (i.e. unsafe acts or conditions) did the near miss or hazard present that could have resulted in injury or illness?

Provide any other relevant information regarding the near miss (i.e. contributing factors, property damage).

What actions, if any, have been taken (include names or departments, where possible) to prevent this situation from occurring in the future? Provide a general timeline, if available

Any other suggested corrective actions? Please include who will be involved in the follow-up if known.

Contact Information

Completion of this section will facilitate OHS follow-up, but is not mandatory. Anonymous forms are also accepted.

Contact Name

Contact Phone Number

Contact email address

Was this reported to anyone else?

Yes

If yes, please provide name

Were you directly involved in the near miss?

Yes

Were there any witnessess?

Yes

If yes, provide name

The personal information collected on this Incident Form is collected under authority of Municipal Act. This information will be used for the purposes of documenting near miss incidents and any necessary follow-up as may be required in accordance with said legislation. Questions about the collection of personal information should be directed to the Office of the City Clerk, or reached at 905-688-5601 ext. 1569 or privacy@stcatharines.ca.

Questions specific to the Municipal Freedom of Information and Protection of Privacy Act, can be directed to the Office of the Clerk (905) 688-5601 ext. 1569 or privacy@stcatharines.ca.