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* Hazard Observation Date / Time:

Date
Time

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* First Name:

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* Last Name:

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* Email Address:

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* Manager's First Name:

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* Manager's Last Name:

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* Manager's Email Address:

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* Provide a short description of the hazard:

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* Is this a Stop Work situation (did you have to stand down from work until the issue was resolved)?

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* Was this a Near Miss (did something happen that you had to react to, but no actual harm occurred)?

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* Has this hazard been corrected?

T