Sample Form For Performing A Simple Root Cause Analysis Of An Injury Or A Near Miss Event Page 2

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Event Tracking Number_________
Root Cause Analysis Action Plan
Risk Reduction Strategies
Measure(s) of Effectiveness
Responsible Person(s)
Action item #1
Action item #2
Action item #3
Action item #4
Action item #5
A-9 Sample Form for Performing a Simple Root Cause Analysis
Page 2 of 2
Sharps Injury Prevention Workbook:

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