ࡱ> :<9[ #bjbj ."ΐΐ 55555III8 DIhjjjjjj$522255(((2^55h(2h(((?&|EIv(T0((5(,( X"2222 :  Date Received by HR Office___________ Report of Unsafe or Unhealthful Working Condition or a Near Miss Incident This form is provided for the assistance of employees at 91ƬN and is not intended to constitute the only method by which a report may be submitted.Briefly describe the near miss incident or the hazard which exists, including the approximate number of employees and students exposed to or threatened by this hazard: Location of unsafe or unhealthful condition or near miss incident: Please be as specific as possible. Does this hazard immediately threaten death or serious physical harm or property/environmental damage? ( Yes ( No ( Unsure Do you have suggestions for corrective actions that could eliminate this hazard, or if it was a near miss, actions that could prevent it from happening again? Is this the first time this hazard or near miss has been reported? ( Yes ( No ( Unsure If this has been reported previously, when was it reported? Name of person reporting condition (optional): Date of incident or hazard recognition:Department: Phone #Name of person responding to report: Date of response:Action taken: SEND FORM TO Sharon Caven C.H. 305 WHEN COMPLETEDA near miss is defined as an incident that has the potential to cause serious injury or property damage. The incident reveals a physical condition or employee action that could lead to future serious injury or property damage if not corrected.     ()tu " i     "#ùhD))jhD))Ujhx,0JUh'z56\]h756\]hx,56\] jhx,hx,B*ph h&56 hx,56hx,5CJ OJQJ^J hx,5hx,)()_tu Ykd$$Ifl$$04 la$If$a$ ! " # $ EYkd$$Ifl$$04 la$IfYkd|$$Ifl$$04 la R S T U Ykdt$$Ifl$$04 la$IfU V + EYkdl$$Ifl$$04 la$IfYkd$$Ifl$$04 la+ , T U lkd$$Ifl0$L04 la$If $Iflkdz$$Ifl0$L  04 la  $Ifgd'z$Iflkd$$Ifl0$L  04 la   !"#Ykd$$Ifl$$04 la ,&P/ =!"#$% z$$If!vh5$#v$:V l05$4z$$If!vh5$#v$:V l05$4z$$If!vh5$#v$:V l05$4z$$If!vh5$#v$:V l05$4z$$If!vh5$#v$:V l05$4z$$If!vh5$#v$:V l05$4$$If!vh5L5#vL#v:V l05L54$$If!vh5L5#vL#v:V l05L5/  4$$If!vh5L5#vL#v:V l05L5/  4z$$If!vh5$#v$:V l05$4^ 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH <`< NormalCJ_HmH sH tH NN  Heading 1$$@&a$5CJ OJQJ^J>@>  Heading 2$$@&a$5DA`D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List :@:  Footnote TextCJ@&@@ Footnote ReferenceH*44 Header  !4 "4 Footer  !PK![Content_Types].xmlj0Eжr(΢Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi};~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!Ptheme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3ڗP 1Pm \\9Mؓ2aD];Yt\[x]}Wr|]g- eW )6-rCSj id DЇAΜIqbJ#x꺃 6k#ASh&ʌt(Q%p%m&]caSl=X\P1Mh9MVdDAaVB[݈fJíP|8 քAV^f Hn- "d>znNJ ة>b&2vKyϼD:,AGm\nziÙ.uχYC6OMf3or$5NHT[XF64T,ќM0E)`#5XY`פ;%1U٥m;R>QD DcpU'&LE/pm%]8firS4d 7y\`JnίI R3U~7+׸#m qBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCM m<.vpIYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07%<ҍPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 +_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!Ptheme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] #" # U +  # 8@0(  B S  ?Y4]$$>*urn:schemas-microsoft-com:office:smarttags PersonName >  !$_` !$33(^_jjssttQV+SUU$ $D))&'z7x,@ #@UnknownG* Times New Roman5Symbol3. * ArialA BCambria Math"1hnC|&fԈ - - Y4d2HX?72!xx$Date report completed:______________Marilyn CameronhoppeOh+'0  ( H T ` lx(Date report completed:______________Marilyn Cameron Normal.dotmhoppe12Microsoft Office Word@@dn@vI̽@PXr|E-՜.+,D՜.+,\ hp  MONTANA TECH  %Date report completed:______________ TitletH0H`h_AdHocReviewCycleID_EmailSubject _AuthorEmail_AuthorEmailDisplayName_PreviousAdHocReviewCycleID_ReviewingToolsShownOnce'J Workers' Compensation Web Pagecaven@msun.eduSharon Caven#  !"#$%&'(*+,-./02345678;Root Entry F&2|E=Data 1TableWordDocument."SummaryInformation()DocumentSummaryInformation81CompObjy  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89q