Synergo LLC
www.teamsynergo.com - 503.746.6646
15995 SW 74th Ave STE 200, Tigard Oregon 97224
NEAR MISS FORM
Near Miss: Something that could have resulted in injury but did not.
Name (Optional):
Date/Time Observed:
Element/Location:
When did the event occur?
Weather:
Follow Up Required?
Yes
No
Witness Name/Phone:
DESCRIBE THE NEAR MISS. WHAT HAPPENED?
WHAT FOLLOW UP MEASURES WERE TAKEN OR SHOULD BE?
Person responsible for follow-up:
Date follow-up completed:
** Return this form to a Manager **
Document created by Synergo
15995 SW 74th Ave Suite 200 Tigard, Oregon 97224
www.teamsynergo.com (503) 746-6646 phone
Preview PDF
Submit
Should be Empty: