TF SAFE CMMS - 2 Minute Near-Miss Report

Location:*

Time:

Date:*

Site (if applicable):

Severity Level:*

REDHigh - Immediate danger avoidedYELLOWMedium - Potential for serious injuryGREENLow - Minor incident avoided

Check Appropriate Box(es):

Unsafe ActUnsafe EquipmentUnsafe ConditionUnsafe Use of Equipment

Description of Near Miss:*

Name:*

Signature:

2 Minute Near-Miss Report Form