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January 23, 2020
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Local 57 Close Call - Near Miss Report Form
Sample form below. You can edit this form and edit this text. The text will show up at the top of the form page, just as you see it now. You can edit the form using the buttons above.
First name:
Last Name:
Email Address:
Employer:
Classification (s):
Work Location (s):
Date (s) of Incident (s):
Location (s) of Incident (s):
Description (s) of Incident (s):
Potential Safety Violation (s):
Equipment Involved:
Step (s) taken to prevent re-occurrence (s):
Comments:
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