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Download LOGO HSE INCIDENT/ nearmiss fORM Report Status: Preliminary Type: Incident Incident No: General Information Evaluation of Risk Incident Date: Loss Severity Potential: Incident Time: Company Name Location of Incident: Probable Recurrence Rate: Section: Employee Name/ID No Occupation: Service In The Job Supervisor/Incharge: Shift: Witness: Events Leading up to and Description of Incident (Include Description and Losses) (What, When, Where, Why, Who, How) Cause Analysis – Dir