Tim White

Cooper Tire Near Miss Report

Near Miss Reporting Form

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Information

Document No.
Near Miss Report
Conducted on
Prepared By:

Date / Time
Department:
- Mixing
- Material Prep
- Tire Assembly
- Curing
- Finishing
- Warehouse
Location:
Description:
Reported To:
- Department Leader
- Bill Cassilly
- Pete Betts
- Robert Strickland
- Ray Powell
- Terry Weeden
- Paul Park
- Ken Midkiff
- Barry Poole
- Sonny Shelton
- Ricky Houston
- Terry Hunsicker
- David Foster
Immediate counter measures:
Long term corrective action:
Photo:
Sketch:

Tim White

Cooper Tire Near Miss Report

Near Miss Reporting Form

Use this Template

Print as PDF

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.