Good Catch/Near Miss Form
Date of Incident
*
/
Month
/
Day
Year
Date
Time of Incident
*
Hour Minutes
AM
PM
AM/PM Option
Job Name
*
Job Number
*
Submitters Name
*
Title of Submitter
*
Submitters Telephone
*
Please enter a valid phone number.
Submitters Email
*
example@example.com
Name of Individual(s) Involved
*
Title/Position of Individual(s) Involved
Witness Name
Witness Phone Number
Good Catch/Near Miss Location – Site of Incident Building Name, Room #, Stairs, Hallways, etc If Outside of Building, Give Location in Reference to Nearest Building.
*
Good Catch/Near Miss Description (Fully Describe the Protocol/Procedures Being Followed Including All Substances/ Equipment, and Machinery Being Used Related to the Near Miss)
*
Personal Protective Equipment (PPE) Used (If Applicable)
What was done to correct the situation?
Upload pictures and documentation if applicable
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