• NAME OF PERSON WHO HAD THE NEAR MISS

  • NAME OF PERSON REPORTING THE NEAR MISS (if you did not have the near miss)

  • NEAR MISS DETAILS

  • Location
  • DESCRIBE WHAT HAPPENED (include pictures in the box below if possible)

  • Picture of near miss

  • WHAT WAS THE POTENTIAL INJURY.

  • COULD THIS HAVE BEEN AVOIDED.

  • Could any of the following have helped to a avoid this near miss?

  • PPE

  • Training

  • Toolbox talk

  • Name

  • NOW SEND THIS FORM TO YOUR MANAGER.

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