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1 <br /> NEAR-MISS REPORT <br /> Project no. &name: Task no. <br /> ' Project address: <br /> Date/time of near-miss: <br /> ' Name of Preparer. Date: <br /> ' The following is an account of what happened: <br /> ' I believe this could have resulted in injury and/or damage to(check all that apply): <br /> ❑ Personnel ❑ Property ❑ Equipment <br /> ' If these circumstances occurred: <br /> 1 <br /> ' I recommend the following actions to prevent this from occurring in the future: <br /> 1 <br /> 1 <br /> ' REVIEWED BY: <br /> Project Manager: Date: <br /> ' Site Health and Safety Supervisor: Date: <br /> ' Ami AdhA <br /> &Associates.lnc. <br />