Submit a Near Miss Report

Thank you for reporting this Health & Safety event.

First Name

Last Name

Phone number

Date

Time of event

Brief description of Task and Near Miss

Location

Please provide full address

Action taken

Attach photos

Declaration & Agreement

I declare that the information I have provided on this form is a true record of the event being reported.
IMPORTANT: I have notified/will notify my Site Supervisor of this Near-Miss!
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