Near Miss - Safety Improvement Form

NM SIF Department

NM SIF Location

NM SIF Date

NM SIF Near Miss or Safety Improvement

Near Miss

Safety Improvement

NM SIF Description of Near Miss or Safety Improvement

NM SIF Reporting Persons Name

NM SIF Reporting Persons Supervisor Name

NM SIF Reporting Persons Signature

NM SIF Witness

NM SIF What type of injury could have occurred

NM SIF Causes ( primary & contributing)

NM SIF Corrective action taken

NM SIF Supervisor Signature

NM SIF Date Completed

NM SIF Not completed for the following reason:

WR AI Claim Number