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Please provide address, specific location, customers name, below
Location of Near Miss being Reported
Team Members Name (optional)
Supervisors Name:
Serious Injury Fatality (S.I.F.) ?
Yes
No
Serious Injury Fatality S.I.F. (Precursors)
No 1 - Did the event involve exposure to acute failure, override, or a failure to use a critical safety feature on a piece of equipment?
No 2 - Did the event involve exposure to a collapse, overturn or partial/complete failure of equipment/finished goods that was newly erected/built/tested or commissioned?
No 3 - Did the event involve a Team Member exposure to a fall from height?
No 4 - Did the event involve exposure to a release of hazardous energy due to ineffective lockout during maintenance, installation, inspection, repair, service or troubleshooting?
No 5 - Did the event involve exposure to being crushed, trapped entangled or in the line of fire with either a release of significant energy or weight?
No 6 - Did the event involve the movement of long and/or heavy unbalanced objects?
No 7 - Did the event involve exposure to potential fire/explosion during hot work on a finished product or with an oxy-acetylene system?
No 8 - Did the event involve potential or actual contact with "live" electricity?
No 9 - Did the event involve potential or actual harm to a person from a motorized vehicle (includes operator and pedestrian)?
No 10 - Was this an actual life altering, life threatening or fatal event?
Type of Near Miss being reported ?
*If other please list in here
Description of Near Miss being reported:
Insert photograph of Near Miss being reported here (please remember confidentiality and no TMs faces)
Description of immediate corrective actions
Gary Meighen-Watts
TSNA Near Miss Report
Near Miss report form for Field Service Technicians and Operations
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