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Employees
Time Entry
Near Miss Report
Date of Incident:
*
Time of Day:
*
Where incident occured:
*
home
work
Weather Conditions:
*
Vehicle/ Equipment Damage
*
Cause of Incident:
*
equipment failure
human error
weather
work practice or procedure
unkown
Number of people involved:
*
Summary of incident:
*
Was safety equipment provided:
*
yes
no
n/a
Was safety equipment in use at the time:
*
yes
no
n/a
Employee's name (Optional):
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