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Get Near-Miss Report Form

use of malfunctioning equipment, or unexpected reactions are examples of near-misses. It is everyone’s responsibility to report and correct these potential hazards immediately. Please complete this form as a means to report these near-miss situations and help prevent future incidents at Texas Tech University. Department: Building: Time of Incident: ☐am ☐pm Room #: Date of Incident: Designation: ☐Faculty ☐Staff ☐Student ☐Other: Check all appropriate conditions: ☐ Near miss.

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