• 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.) ?

  • Serious Injury Fatality S.I.F. (Precursors)

  • 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

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