"Near Miss" Incident Report** All Submissions Remain Anonymous **Name: (This can be left blank if you choose to remain anonymous. If your name is recorded, it will be kept confidential.) Date of Incident: Time of Incident: Incident Reported to: Date of Incident Reported: Time of Incident Reported: Location of "Near Miss" Incident: Names of Employees Involved: Names of Witnesses: What task or job was being performed? Who was the supervisor at the time of the incident? What caused the "Near Miss"? For Administrative Use OnlyCorrective Action: Person Responsible for Corrective Action: Date Corrective Actions Completed: HomeSecurityAboutTestimonialsServicesSupport24/7 MonitoringRemote SupportWeb DesignWeb Design PackagesWeb Care/MaintenanceWebsite EvaluationBlogContact Us