Near Miss Report

Department / Location:

Location(s)

Kwik Trip / Kwik Star FARGO
Oriska Rest Stop

Due to issues with these locations being submitted, please use the check box option instead of the department/location box. In the department/location box, please type See Below.

Incident Check (Primary

Date / Time of Incident *

Date

Time

Please Check All Appropriate Conditions:

Unsafe Act
Unsafe Condition
Unsafe Equipment
Unsafe Use of Equipment

Please Select Who Was Involved: *

Internal Employee or Environment
Subcontractor

Subcontractor Name (if applicable):

Description of Incident or Hazard *

Causes (Primary & Contributing) *

Corrective Action Taken (Remove the Hazard, Replace, Retrain, Etc) *

Upload a Photo

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Name *

First

Last

By submitting this form with your first and last name, counting as your electronic signature, you are claiming the information provided in this form to be true based on you witnessing the above reported near miss.

Date of Submission *