Near-Miss Incident Report Form

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This form is used to help identify possible safety concerns and will not be used for repercussion but as a teaching tool.

Personal Information
Position
Location Information
Incident Information
Type of incident
Incident occurred during
Was University police or 911 called?
Was there an injury?
Injury Information
Type of injury (Check all that apply)
Was the victim wearing personal protective equipment? (Check all that apply)
LSO/TA Information
PI/LS Information
Safety Suggestions
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