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NEAR MISS
A near miss is an unplanned event that did not result in injury, illness, or damage – but had the potential to do so.
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Name:
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Location of near-miss:
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Date of near-miss:
MM
/
DD
/
YYYY
Time of near-miss:
Time
:
AM
PM
Please describe the near-miss you witnessed:
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Names of any other witnesses:
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