Near Miss 1

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* 1. Name (optional)

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* 2. Date and Time of Near Miss

Date / Time

Date

Time

AM/PM

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* 3. Employee Group

Engineering

Field Customer Service

General Office

Grounds

Central Stores

WD - Leak Locate

WD - Pipelines

WP - Maintenance

WP - Operators

WP - Lab

Garage/Fab/Bld Maintenance

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* 4. What happened?

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* 5. How would you recommend mitigating this risk?

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* 6. If you have one, upload a photo below.

PNG, JPG, JPEG file types only.