LEO INDUSTRIAL SERVICES LLC · Goshen, OH · service@leoindustrialservices.com
Incident / Near-Miss Report
Incident / Near-Miss Report
1. What type of event?
☐ Injury / illness ☐ Near-miss ☐ Property / equipment damage ☐ Chemical exposure / spill ☐ Vehicle incident ☐ LOTO or safety-rule violation observed
2. When and where
| Date & time | LEO Job ID | WO-2026-____ | |
|---|---|---|---|
| Customer / site | |||
| Exact location / equipment | |||
3. People involved
| Name | Role (LEO / customer / other) | Injured? (Y/N) | Phone (work) |
|---|---|---|---|
4. What happened
Step by step, facts only: what was being done, what went wrong, what happened next. Take photos before anything is moved (unless moving it prevents further harm).
5. Injury details (if any)
| Body part / type of injury | |
|---|---|
| First aid given / by whom | |
| Medical treatment | ☐ None ☐ Clinic / urgent care ☐ Emergency room ☐ 911 / ambulance |
| Customer notified (name, time) |
6. Why did it happen? (immediate and underlying causes)
☐ Energy not isolated / LOTO ☐ Missing or bypassed guard ☐ Wrong / no PPE ☐ Procedure not followed ☐ No procedure ☐ Equipment failure ☐ Housekeeping / slip-trip ☐ Rushing / fatigue ☐ Communication ☐ Other ________
7. Corrective actions
| Action | Owner | Due | Done |
|---|---|---|---|
8. Sign-off
| Reported by (name, signature, date) | |
|---|---|
| Witnesses | |
| Reviewed by Neil Inabnitt (signature, date) | |
| Workers comp claim filed? | ☐ N/A ☐ Ohio BWC ☐ KEMI (Kentucky) Claim # ________ |