Near Misses Form
Date
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Time
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Report Type
Unsafe Acts & Conditions
Hazard
Incident/Accident
Work Group
Please enter a work group.
Location
Please enter a location.
Department
Please enter a department.
Number of People
Please enter the number of people.
What Happened
Please describe what happened.
Action Taken
Please describe the action taken.
Further Action Required
Reported By
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Supervisor
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Status
Pending
Ongoing
Suspended
Completed
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