Superintendent's Near Miss Report

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

SECTION I

• Date and time of incident

  Date

• Nature of the incident (i.e. fall, struck by, caught between, slip/trip)

• Add media

  Media

• What Happened

• How / Why did this happen:

• What is being done to prevent recurrence?

• Was there any witness(es)? If yes, provide name(s).

  Yes

  No

  N/A

Distribution List:

• Ray Boehm

• Shane Spears

• Ren Harwell

• Larry Havel

• Justin Fuhrman

• Denver Moody

• Charles Berg

• Pete Hyatt

• Aaron Fretwell