Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Type of Near Miss
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Choose one....
Description of Near Miss
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Take a photo? (optional)
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Did I do something to fix the Near Miss? If so, what?
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Suggestions on how to prevent re-occurrence...
Signature (optional
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Team Member Signature
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Do you want to get a Reply from the Safety Commitee
Action taken by Commitee
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Safety Committee Reviewed Report
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Committee Recommendation...
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Employee Co-Chair
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Management Co-Chair
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EHS Review