WP - NEAR MISS REPORT

NEAR MISS REPORT
This report is to be filled out by any employee involved in or witnessing a near miss. A near miss is an incident that did not result in any personal injury, property damage or production interruption. It is a very important indicator of potentially harmful future accidents.
Department*
Date of Incident*

MonthDayYear
Time of Incident*

AM/PM Option
Location of Incident*
Description of Incident or Potential Hazard*
By checking this box, you affirm that the information provided above is true, complete, and accurate to the best of your knowledge.
Signature

Clear
Should be Empty: