Max Forms
Home
Admin Login
Submit Near Miss
Enter Security Pin:
Near Miss Form
Date
Time of Near Miss
Your Name
Company Name
Reported to
Position
Describe The Near Miss
What Action Was Taken
Severity of Potential Incident
Make a Selection
Minor
Serious
Major
Potential For Reoccurrence
Make a Selection
No
Yes
Has the hazard been addressed and resolved?
Make a Selection
No
Yes
Further Corrective Action Assigned to
Your Email
By clicking Submit, you agree to our
Privacy Policy for Hiperion Corporation
.
Submit
Done - Return to Dashboard