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 Description continued on attached sheets:  Step 3: Why did the incident happen Unsafe workplace conditions: (Check all that apply)  Inadequate guard  Unguarded hazard  Safety device is defective  Tool or equipment defective  Workstation layout is hazardous  Unsafe lighting  Unsafe ventilation  Lack of needed personal protective equipment  Lack of appropriate equipment / tools  Unsafe clothing  No training or insufficient training  Other:  Unsafe acts by people: (Check all that apply)  Operating without permission  Operating at unsafe speed  Servicing equipment that has power to it  Making a safety device inoperative  Using defective equipment  Using equipment in an unapproved way  Unsafe lifting  Taking an unsafe position or posture  Distraction, teasing, horseplay  Failure to wear personal protective equipment  Failure to use the available equipment / tools  Other:  Why did the unsafe conditions exist Why did the unsafe acts occur Is there a reward (such as “the job can be done more quickly”, or “the product is less likely to be damaged”) that may have encouraged the unsafe conditions or acts  Yes  No If yes, describe: Were the unsafe acts or conditions reported prior to the incident  Yes  No Have there been similar incidents or near misses prior to this one  Yes  No 4 Step 4: How can future incidents be prevented What changes do you suggest to prevent this incident/near miss from happening again  Stop this activity  Guard the hazard  Train the employee(s)  Train the supervisor(s)  Redesign task steps  Redesign work station  Write a new policy/rule  Enforce existing policy  Routinely inspect for the hazard  Personal Protective Equipment  Other:  What should be (or has been) done to carry out the suggestion(s) checked above Description continued on attached sheets:  Step 5: Who completed and reviewed this form (Please Print) Written by: Tit