Near Miss - Safety Improvement Form
date_time
2025-10-31 09:36:04
id
NM SIF Department
NM SIF Location
NM SIF Date
NM SIF Near Miss or Safety Improvement
NM SIF Conditions
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