Near Miss
Prepared By
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First Name
Last Name
First and Last Name(s) of employee(s) involved
*
Line of Business
*
Please Select
Construction
Asphalt
Aggregates
Ready-mix Concrete
Equipment
QC
Location / Line of Business
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Construction Job / Location Details
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Location of Near Miss
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Date
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-
Month
-
Day
Year
Date
Time of Incident
Hour Minutes
AM
PM
AM/PM Option
Description of Near Miss:
What almost happened? What hazard was identified?
Lessons Learned
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What was learned about how this happened?
Corrective Actions
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What actions were taken to improve safety?
Equipment Number
Enter the equipment number if any company equipment or vehicles are involved in the incident.
Additional Information
Is there any additional information we should know?
Photos and Documentation
Take photos that would better describe the near miss.
Photo #1
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Photo #2
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Location / Line of Business
Photo #3
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