Email any supporting photos or documents if necessary to: eamon@connellyandassociates.com Name Position Date of Near Miss Name of Person Completing Form (Last, First, Middle Initial) Contact Phone Number: Witness Name (Last, First, Middle Initial) Witness Phone Number: Location of Near Miss Near Miss Description: Describe procedure being followed, including equipment which was related to the near miss. Corrective Actions: What should be done or has been done to prevent recurrence of this incident? Ex: employee training, change of procedures, purchasing of equipment, etc. Miscellaneous Information (Provide any other information or recommendations which you feel are pertinent to the incident)
Address 1513 Tilco DriveFrederick, MD 21704 Phone (301) 696-8820 Business Hours Monday - Friday: 9:00am - 5:00pmSaturday - Sunday: Closed
