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Near Miss / Hazard ID
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Near Miss / Hazard ID
Date
Time
Type of Event
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Near Miss
Hazard Id
Your Name
Company Name
Reported to
Position
Describe The Event / Hazard
What Action Was Taken
Severity of Potential Incident
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Minor
Serious
Major
Potential For Reoccurrence
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No
Yes
Has the issue been addressed and resolved?
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No
Yes
Further Corrective Action Assigned to
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