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r..r <br /> GROUNDWATER 'Ir-O-DqOLOGY. Leif <br /> A=.dent/Inc:dent (near miss) Report <br /> - Employee's Name: D.O.B. <br /> D.O.Ii <br /> Address: SSx <br /> Job Titic: Supervisor's Name: <br /> Office Location: <br /> Location at Time of Incident: <br /> Datefrime of Incident• <br /> Describe clearly how the accident occurred: <br /> Was incident: Physical Chemical <br /> Parts of body affected Exposure: Dermal <br /> right left Inhalation <br /> Ingestion <br /> Witnesses: 1) 2) <br /> Conditions/acts contributing to this incident <br /> Managers must complete this section: <br /> Explain specifically the corrective action you have taken to prevent a recurrence:,_____,_ <br /> Did injured go to doctor. Where: <br /> When: <br /> Did injured go to hospital: Where: <br /> - <br /> When: <br /> Signatures: <br /> Employee <br /> Reporting Manager Health &. Safety Manager <br /> Date <br /> Date Date <br /> This form must be completcd and returned to Health andSafety <br /> Scty Dtor at II,D.workingwithin 5 <br /> days. lie manager willforward a copy to Corporate Health <br /> a <br /> axis-m-M <br />