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i • <br /> Kennedy/Jenks Consultants <br /> Near-Miss Report Form <br /> This form should only be used for Near-Miss events which did NOT result in injury or property damage. Use the <br /> Injury/lllness Report Form to record injuries or illness. Use the Property Damage Incident Report Form to record <br /> property damage. <br /> Date: Location: <br /> Time: ❑a.m. ❑p.m. <br /> Weather Conditions: <br /> Please check all that apply: <br /> ❑Unsafe Act ❑Unsafe Condition ❑Unsafe Equipment ❑Unsafe Use of Equipment <br /> Description of Near-Miss in detail: <br /> Employee Name Date: <br /> ------------------------------------------- <br /> This section to be completed by Health & Safety Manager or Representative. <br /> Cause of Near-Miss: <br /> Corrective action(s) taken: <br /> Business Unit H&S Manager Date: <br />