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Near Miss Notification Form

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Near Miss Notification Form

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Audit

Instructions: 1. Required to be completed when you experience a Safety Near Miss in the workplace2. To be completed in full and emailed to direct manager or the Health & Safety Manager.

Near Miss DefinedOSHA and the National Safety Council defines a near miss as an “unplanned event that did not result in injury, illness or damage – but had the potential to do so.”

Date & Time of Near Miss:

Location of Near Miss. If customers site, please provide address

Select the category the near-miss most relates to:

Describe how the Near Miss occurred (include the body part and type of pain):

Describe what lead up to and caused the Near Miss. Identify root causes:

What was learned and changed due to the Near Miss?

If a photo will help explain the what, where, why, or the injury upload the picture here:

Choose your level of anonymity for this near miss report

By my signature below I attest that the information I have provided is true and accurate to the best of my knowledge:

Signature:

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