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Facilities Management

Near Miss Report

NEAR MISS: a potential hazard or an unplanned event that did not result in an injury illness, exposure or damage, but had the potential to do so. There was NO slip, trip, fall, punch, poke, bruise, strain, fire or exposure.

Form Instructions

  1. Within 24 hours the witness or person with knowledge of near miss/potential hazard must complete Section 1.
  2. Fax immediately to the Security Office at 701-858-3002.
  3. The person who completed Section 1, must give the form to their supervisor.
  4. Supervisor must conduct an investigation and complete Section 2.
  5. Upon supervisor’s completion of Section 2, the entire form must be faxed to the Security Office at 701-858-3002.

Near Miss Report Form [pdf]