________________________________

________________________________

________________________________

________________________________

Please return to 

your local DLA 

Safety and Health 

Office (SHO)

How do I report a near miss or 

hazardous condition? 

 

Fill out the opposite side of this form. 

 

Determine if you can do something to resolve the 

safety problem yourself. If you can, do so and note 

it on the form. 

 

Send a copy of the form to your local DLA Safety 

and Health Office (SHO). 

 

What's a near miss? 

 

A near miss is an event that could have caused 

a serious injury or illness, but didn't. For 

example: 

 

Someone spills coffee or water on the floor and 

does not clean it up. Someone slips but is not 

injured. 

 

A forklift operator takes a turn too quickly and drops 

the load which almost hits a nearby worker. 

 

What's a hazardous condition? 

 

A hazardous condition is a condition that could 

cause an accident or - an accident waiting to 

happen. For example: 

 

Water or other material(s) on the floor that could 

cause a slip or fall. 

 

A frayed electrical cord in your office. 

 

How do I correct a safety problem? 

 

Take any action you can to reduce the chance 

that an accident will happen or that someone 

will get hurt. You might: 

 

First contact your supervisor/work leader if 

additional resources are needed to correct the 

problem. 

 

Contact the Facilities Department/maintenance 

provider to report a maintenance problem and 

complete a work order. 

 

Contact your local DLA Safety and Health Office. 

Employees who are in a bargaining unit may also 

notify their union representative. 

If you are dissatisfied with the response, you 

are encouraged to take the following actions 

in the order listed below:

1. Contact your local DLA SHO: 

 

 

2. Forward your concerns to the 

 local DLA Commander: 

 

 

3. Forward your concerns to 

 DLA's Designated Safety and 

 Health Official at:

NEAR MISS / HAZARD 

REPORT

DLA 

ATTN: Chief of Staff 

8725 John J. Kingman Road 

Fort Belvoir, VA 22060-6221 

DLA FORM 1404, FEB 2008 PDF (DLA) DLA FORM 1404, FEB 2008 PDF (DLA)
Near Miss / Hazard Report Form

Purpose of this form: 

 

To report a near miss/unsafe act or hazardous 

condition, please complete this Safety Action 

Report. 

 

Where did the near miss happen or where is 

the hazardous condition? (Be specific) 

 

Building (Name/Number) __________________ 

 

Room/hallway/parking lot _________________ 

 

Geographic Location _____________________ 

 

When did the near miss happen or when did 

you discover the hazardous condition? 

 

Date ______________Time________________ 

 

What department(s) were involved or 

impacted in the near miss or hazardous 

condition? 

 

_______________________________________ 

 

Was the near miss/hazardous condition 

reported to your supervisor/work leader? 

 

 YES NO 

 

Name of Supervisor/Work Leader: 

 

_______________________________________ 

 

Reporting Employee (Name Optional) 

 

Name __________________________________ 

 

 Please keep my name confidential 

 

Office Symbol __________________________ 

 

Phone _________________________________ 

 

Your name and number is helpful so that we 

can obtain additional information if necessary, 

and is needed if you want to receive a 

personal response.

Describe in detail how the near miss occured 

or what the hazard is: 

_______________________________________ 

 

_______________________________________ 

 

_______________________________________ 

 

_______________________________________ 

 

_______________________________________ 

 

List any safety equipment, if any, being worn 

at the time of the near miss: 

 

_______________________________________ 

 

_______________________________________ 

 

_______________________________________ 

 

_______________________________________ 

 

In your opinion, were there any unsafe 

conditions or acts which contributed to the 

near miss or hazardous situation? Please list: 

 

_______________________________________ 

 

_______________________________________ 

 

_______________________________________ 

 

_______________________________________ 

 

 

List the names of any witnesses who 

observed the near miss or hazardous 

condition. (Optional) 

 

_______________________________________ 

 

_______________________________________ 

 

_______________________________________ 

 

_______________________________________ 

What corrective action did you take or do you 

recommend? 

 

Please note what corrective action you were 

able to take or what other corrective action 

you recommend. Check the appropriate box 

below and explain. 

 

 I corrected the safety problem myself 

 

 My supervisor/work leader and/or I 

 could not correct the problem, 

 recommend the following corrective 

 action: 

 

_______________________________________ 

 

_______________________________________ 

 

_______________________________________ 

 

_______________________________________ 

 

 

 

 

Final disposition: _______________________ 

 

_______________________________________ 

 

_______________________________________ 

 

_______________________________________ 

 

Date Received by SHO: __________________ 

 

Reviewed by: __________________________ 

 

 Reporting Employee Notified 

 

 

_______________________________________ 

Signature of Safety and Health Manager 

 

Date Signed ____________________________ 

 

SHIRS Tracking Number: 

To Be Completed by Safety & Health Office

DLA FORM 1404, FEB 2008 PDF (DLA)