ACCIDENT REPORT

Near Miss Report
Please be specific and professional in your responses
* Required
Property: *
Choose
Keana Farms
Smoky Mountains
Form Completed By: *
First and Last
Your answer
Date of Near Miss: *
MM
/
DD
/
YYYY
Tour Time:
Time
:
AM
PM
Guides: *
List all guides on your tour
Your answer
Witnesses:
Other employees, guests, etc
Your answer
Location On Course: *
Be Specific (e.g. End of Line 1 or Rappel 2)
Your answer
Type of Near Miss:
Choose
Participant unclipped from course
Guide unclipped from course
Hard Prusik Stop
Radio or Course Calls
Other (Explain in next section)
Describe Near Miss: *
Be specific
Your answer
Action Taken: *
How was the near miss handled?
Your answer
Corrective Action Taken: *
Your answer
Manager Signed Off: *
Choose
Mike Murray
Seth Estioko
Sage Kaka
Jesse McVey
Doran Wildridge
Brant Liufau
Kami Tauiliili
Phil Rhodes
Brian Turley
Jarrad Read
Brandan Owen
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