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Near Misses Register

Project: Month: / 2013


No Location Person/ Company Date Time

Address:

Appropriate conditions 1. Unsafe Act 2. Unsafe Condition 3. Unsafe equipment

Appropriat e conditions

Potential Hazard

What happened?

Corrective Action taken

Date Completed

Done

1 2 3 4 5 6 7 8 9
Reported by: Signature:

O O O O O O O O O

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