Information
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Client / Site
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Conducted on
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Prepared by
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Personnel involved
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Type of near miss
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PPE infraction
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Equipment/vehichle
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Safety equipment i.e. missing stinger, missing vac break, etc.
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Other
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Brief description of near miss
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Employee designation
- Supervisor
- Crew Leader
- Operator
- Technician
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Is personnel involved a short service employee
- yes
- no
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Describe Corrective Action Taken
