FIRST CARE HEALTH NEAR MISS REPORT

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DATE:     TIME:        REQUESTED BY:    

Use following format: 01/01/2007, Time: 12:42, Requested By: firstname.lastname (email format)

   LOCATION:  

NEAR MISS:        PROBLEMS:

                   If "Other" chosen in PROBLEMS entry, be specific in text box below:

                                                                    

   DESCRIBE UNSAFE ACT, CONDITION, ETC.:

        

                                               

 The Following Portion To Be Completed By Maintenance, Supervisor or Lead
  Identify Causes:

  Correction Action Taken (Remove, Replace, Repair etc. the hazard)

  Date Completed:

  Not Corrected for the following Reason:

 

   Signed:                                                                               Date:                                      

  Management Signature:                                                        Date:                                    

   NOTE: MAINTENANCE REPORTS will remain witht he Maintenance Department  NEAR MISS REORTS will go to the Safety Director
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