YOU COULD WIN A $25.00 VISA CARD FOR YOUR “NEAR MISS”!
Employee’s Name: _______________________________________________
Date of event: ____________________
What I learned/would have done differently/changes that might be helpful:
Employee’s Signature ___________________________________
Department Head’s Signature_______________________________________
Please, give your completed form with photo, if possible, to any Safety Committee member or Nancy Hamilton, the Safety Coordinator at Cell (406)230-0922, fax (406)228-9027, or e-mail: email@example.com,
mailing address: 501 Court Square, Glasgow, MT 59230. Completed forms will be reviewed at the next month’s Safety Committee meeting. Chances of winning will depend on number of entries and the Committee’s judgment of quality and substance. All decisions are final. Entrant will be contacted if they win.