Information
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Type of incident
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Name of Employee preparing the report
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Location
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Employee Type
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Employee / person associated with the near miss / incident
Reporting
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Date & Time of Near Miss / Incident
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System or Equipment name related to the near miss
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Were there any witnesses?
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Enter Names
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Select the category the near-miss most relates to:
- Fall from height
- Trip / Fall on same level
- Fall from equipment
- Hazardous Manual Handling
- Electric Shock
- Collision / Hit an object
- Caught between/underneath
- Hazardous Substance
- Falling object
- Other
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Describe how the Near Miss occurred
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Photo/s that can help explain the what, where, why, or the possible injury:
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If possible, identify any root cause(s):
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Signature of employee associated to the near miss