Doc no.

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NEAR MISS REPORT ACONNEX no.:

INCIDENT/ACCIDENT INVESTIGATION Page 1 of 1

Project Area:

Sub Location:

Incident Date and Time

Incident Classification A B C

Description of what happened/was observed

Injury: YES NO [indicate potential injury]

Possible consequences
Damages: YES NO [indicate potential damages]

Personnel Involved Name and Surname Job Position

Check if not applicable:

Equipment Involved Property owner: Arail Utility Municipality Public

Equipment/Plant: Model/Type:
Check if not applicable:

Probable Causes

Actions to be taken

Attachments

Reported by
(optional) Name: Position: Date: Signature:

Prepared by: Name: Position: Date: Signature:

Approved by: Name: Position: Date: Signature: