Near Miss Reporting Form
Would you like to attach your name to this report?
Name
Submitter ID
Email
Phone
Person Affected
Email
Department
Student Affected
Supervisor or Witness
Contact Info
Contact Info 2
Division
Department
Additional Contact Name
Additional Contact Email
Date of Incident
Time
Date Reported
Time
Time Reported to Work
Extra Date
Campus
Location
Room
Division
Department
Accident / Incident
Near Miss
Description of incident.
Medical Treatment
Is there a written SOP for the procedure being performed?
Were there any injuries?
Did anyone seek medical treatment as a result of this incident?
Was there any building damage?
Was there any equipment damage?
Was there any equipment damage?
Was there any equipment damage?
Type of Incident
Source of Incident
Contributing Factors
PPE
Why did it happen? Be specific in describing unsafe acts or conditions that contributed to the cause of the incident.
What corrective actions, if any, have been taken.
What corrective actions have been identified that still need to be implemented? Describe any obstacles preventing the implementation of identified corrective actions.
Question4
Upload Document (.pdf, .jpeg, .jpg, .gif, .txt, .docx)
Additional Details
Submit
Cancel
Submitting Report.
Please wait.