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MPCO – 160
Near Miss Report
MP Construction Office Phone: 530-934-7066 Fax: 530-934-7679
Your report is vital to accident prevention. Please fax or phone in this report within 24 hours of the incident. Name of Worker(s) Contract/Division ______________________________________________________________________________ Date of Near Miss Hour: Exact Location ________________ A.M. P.M. ___________________________ Job or Activity at Time of Near Miss: ____________________________________________________________________________________________________________________________________________________________ Description of Near Miss: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________ Suggested Corrective Action: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Date of this Report Supervisor ________________ ____________________________________ Safety Office Review: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________