Near Miss Report
Time reported to safety manager
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Hour Minutes
AM
PM
AM/PM Option
Completed by
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Date
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-
Month
-
Day
Year
Date
Job Name as it reads in CMIC/Tsheets
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Employees Involved
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Personal Protective Equipment involved:
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Details of Incident
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Suggested Solution
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Has the Hazard(S) been eliminated?
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Yes
No
Upload any photos or documents of the near miss
*
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