Fillable Wenatchee Valley College Hazard / Near Miss Report (Wenatchee Valley College)

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Wenatchee Valley College Hazard / Near Miss Report (Wenatchee Valley College)

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Wenatchee Valley College Hazard / Near Miss Report
Attention: Campus Safety Security and Emergency Management
Definitions
Hazard: A haza
rd is any source of potential damage, harm or adverse health effects on something or someone under certain
conditions at work.
Near Miss: is 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 o
f events prevented an injury, fatality or damage; in other words, a "What almost happened?"
Instructions
Any person who has experienced or witnessed a Near Miss or believes a hazard exists at WVC may submit a Hazard / Near
Miss Report
by completing this form entirely and turning it in to Campus Safety.
Type of Report:
 Near Miss  Hazard
Reported by: Name:
Local Address:
Phone (Work): Phone (Home):
Status:  Employee (Staff / Faculty)  Student  Visitor  Other:
Part I: HAZARD/ NEAR MISS INFORMATION:
Exact Location of
Hazard/ Near Miss:
Describe the Hazard/ Near Miss:
5/2017
Why do you think this is a Hazard?
What do you think could be done to resolve this situation?
Who have you told about this Near Miss/ Possible Hazard?
□
Supervisor

Department Head

No one

Submitted Work Order
Other
:
I verify this information is true and correct. I understand my responsibility to turn this completed form into the SSEM
Manager, Maria Agnew at magnew@wvc.edu, as soon as possible.
Signature
Date
Part II: HAZARD INVESTIGATION
Investigator Name:
Investigator
Title:
Date Report Received by Investigator:
Date
Investigation Started:
Investigative Actions Taken:
Persons Interviewed:
Corrective Actions Recommended:
Risk Control Options
Action Required
By Whom
By When
Elimination – Do you have to do
the task?
Substitution – Is there another
way you can do the task?
Engineering – Can you use tools
or machinery to make the job
safer?
Administration – Can you
improve work practices?
(E.g. limit time of exposure).
Use of Personal Protective
Equipment (PPE) – i.e. safety
glasses, reflective vests, etc. OR
Safety Equipment – i.e. safety
cones, caution tape, warning signs
Date feedback provided to person reporting the hazard:
Signed:
Print Name:
Ph:
Date:
Office Use Only (SSEM Recommendations)
Received By:
Date Completed:
Date Reviewed by
Safety Committee:
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Wenatchee Valley College Hazard Near Miss Report (Wenatchee Valley College)

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Completed 9 October 2020

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