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Non-Injury and Near-Miss Report
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Non-Injury and Near-Miss Report
Non-Injury and Near-Miss Reporting Form
Consent for storing submitted data
*
Yes, I give permission to store and process my data
No, I don't consent to storing and processing my data
Near-Miss Reporting
*
Non-injury
Near-Miss
Warning/Alert
Date of Near-Miss
*
Near-Miss Location
Name of Individual Reporting Incident
*
What Happened
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Describe the incident in as much detail as possible
Refer to your SDS binder for more information
Chemical Name/Hazards
What Could Have Happened
*
Describe how the incident could have potentially resulted in a more serious or life-threatening situation
Contributing Factors
*
Improper Equipment Use
Equipment Malfunction/Failure
Poor Layout/Design
Unsafe Condition(s)
Insufficient Training
Other
If you answered 'Other' Please Describe
Please indicate how the incident can be prevented from reoccurring