• At which plant did this occur?

  • Enter the date and time of the near miss

  • Enter the name(s) of the employee involved

  • Enter the exact location that the near miss occurred (B-Cut, Loading Station)

  • Photo of location

  • List any equipment that was involved

  • Photo of equipment involved

  • Was proper PPE being worn? (If no, explain why)

  • Was company policy being followed? (If no, explain why)

  • Description of the near miss

  • Was a root cause analysis performed? (If no, explain why)

  • List any corrective actions, disciplinary actions, extra training, etc. that is required due to the near miss

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