Information
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Document No.
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Conducted on
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Employee Name (optional):
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Instructions:
1. Required to be completed when you experience a Safety Near Miss in the workplace
2. To be completed in full and emailed to Chris Reynolds, Health & Safety Manager and/or Dee Schlaudraff, Claims Manager -
Choose one:
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Office:
- Fort Myers
- Gainesville
- Jacksonville
- Lake Wales
- Ocala
- Orlando
- Port St. Lucie
- Tallahassee
- Tampa
- Tampa Corp.
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Date & Time of Near Miss:
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Company Cell:
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Vehicle #:
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Location of Near Miss. If customers site, please provide address
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Describe how the Near Miss occurred (include the body part and type of pain):
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Describe what lead up to and caused the Near Miss:
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What was learned and changed due to the Near Miss?
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If a photo will help explain the what, where, why, or the injury upload the picture here:
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By my signature below I attest that the information I have provided is true and accurate to the best of my knowledge:
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Signature:
