Title Page
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Conducted on
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Reported by
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Location
Background Information
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Job site
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Job description
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Add person(s) involved
Person
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Name of person involved
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Title/ Position of person involved
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Supervisor name
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Supervisor contact number
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Were there any witnesses?
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Primary witness name
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Primary witness number
Incident Details
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Date and time of incident
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GPS location of where incident occured
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Description of where incident occured (e.g. 2nd floor)
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Near-Miss Description (Select all that apply)
- Unsafe Act
- Unsafe Condition
- Unsafe Equipment
- Unsafe Use of Equipment
- Other
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Provide details
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Supporting photos of near miss
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Personal Protective Equipment (PPE) used?
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Why was it not being used
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List PPE used
Recommendations
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Corrective Actions - What should be done or has been done to prevent this incident? (examples: employee training, change of procedures, purchasing of equipment etc.)
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Name of responsible party for corrective actions
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General observations
Sign Off
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Signature of person who completed form
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Supervisor review