"Near Miss Report Template"

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Near Miss Report
Reported by:
Date:
Phone #:
Email:
Address:
Recorded by:
Date:
Phone #:
Email:
Address:
Incident
Date of Incident:
Time:
Location:
Equipment Involved:
Unsafe Conditions:
Hazards:
Code Violations:
Safety Violations:
Conduct Violations:
Person(s) Involved:
Description:
Response
Investigation?
q Yes q No
Reported to Supervisor?
q Yes q No
Witness 1:
Phone #:
Email:
Address:
Witness 2:
Phone #:
Email:
Address:
Cause(s):
Corrective Action:
www.ReportTemplates.net
Near Miss Report
Reported by:
Date:
Phone #:
Email:
Address:
Recorded by:
Date:
Phone #:
Email:
Address:
Incident
Date of Incident:
Time:
Location:
Equipment Involved:
Unsafe Conditions:
Hazards:
Code Violations:
Safety Violations:
Conduct Violations:
Person(s) Involved:
Description:
Response
Investigation?
q Yes q No
Reported to Supervisor?
q Yes q No
Witness 1:
Phone #:
Email:
Address:
Witness 2:
Phone #:
Email:
Address:
Cause(s):
Corrective Action:
www.ReportTemplates.net
Incident Report Form

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