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Near Miss Report <br /> Incident Date Reported By Work Unit Project Name Incident Number <br /> Description (What,Where,When,Who, How) <br /> Please check all that apply: <br /> ❑ Unsafe Act ❑ Unsafe Equipment <br /> ❑ Unsafe Condition ❑ Unsafe Use of Equipment <br /> Improper PPE Housekeeping <br /> Why was the unsafe act committed, and/or why was the unsafe condition present? <br /> What Corrective Actions have/will be taken to prevent similar incidents? <br /> Person responsible for follow-up Expected completion date Actual completion date <br /> Verified By: <br /> Supervisor Name: <br /> Signature: <br />