Title Page
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Project Name
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Conducted on
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Prepared by
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Location
Near Miss Details
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Date of Near Miss:
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Time:
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Near Miss Description:
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Location on project site:
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Machinery / Equipment Involved:
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Chemicals / Materials Involved:
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First Aid Treatment Provided:
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Name / Address of Witnesses:
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Near Miss Occurrence as defined in Regulations requiring reporting to Enforcing Authority:
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Comments / Recommendations / Action Taken:
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Signature:
