Laserfiche WebLink
- OTIE- <br /> NEAR MISS OCCURRENCE REPORT <br /> Page 1 of 2 <br /> This report is to be completed following a "near miss" incident that does not result in an injury or <br /> illness. Please answer all questions as completely as possible. Forward this report to the <br /> OTIE SHM within 24 hours of the incident. <br /> Date: l Time of Incident: <br /> Location: City, State <br /> Name of Project/Project No.: <br /> Description of Near Miss Incident <br /> Name(s) of Witnesses: Telephone No: <br /> What unsafe physical condition(s) or unsafe act(s) contributed to the near miss? <br /> What systematic or management deficiencies contributed to the near miss? <br />