Near-Miss Report A “NEAR-MISS” is a potential hazard or incident that has not resulted in any personal injury. Unsafe working conditions, unsafe employee work habits, improper use of equipment or use of malfunctioning equipment have the potential to cause work related injuries. It is everyone’s responsibility to report and/or correct these potential accidents/incidents immediately. Please, complete this form as a means to report these “NEAR-MISS” situations. Region*Select your locationCorpus ChristiMidlandKilgoreLafayetteIncident Date* Date Format: MM slash DD slash YYYY Date Reported Date Format: MM slash DD slash YYYY Time : HH MM AM PM Department/LocationOperations / Casing ServicesOperations / Tubing ServicesSafetyNature of Condition(i.e.: Unsafe Act, Unsafe Condition, Unsafe Equipment, Unsafe use of Equipment)Description of Incident or Potential HazardEmployee Name* First Last WitnessesNEAR-MISS INVESTIGATIONDescription of the “NEAR-MISS” ConditionCauses (Primary & Contributing)Corrective action taken(Remove the Hazard, Replace, Repair or Retrain in the proper procedures for the Task)Investigated by:* First Last District Manager: First Last Date Completed Date Format: MM slash DD slash YYYY Not completed for the following reasonsMARC CAMACHO – HSE / Fleet Mgr. Cell: 956-874-4530 Email: mcamacho@pipe-pros.com