Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
Untitled Page
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Are you reporting a hazard or near miss?
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Description of hazard or near miss?
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My suggestion for removing hazard or preventing a re-occurence of near miss?
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Name
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Position
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Signed
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Date
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Feedback and record of actions (to be completed by Manager/Supervisor
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Confirmation the hazard/action has been resolved
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Managers name
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Managers signature
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Date
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Originators name
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Originators signature
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Date