Near Miss Reporting Form
A near miss is a safety related incident that does not cause personal injury, damage to equipment or buildings, or require the discharge of a fire extinguisher. If any of the above has occurred, please report the incident at the incident reporting section of the EH&S web site.
Why document Near Misses?:
Documenting near misses provides a mechanism to get EH&S issues communicated and addressed, and, most importantly, serves as an educational tool for all of our colleagues. With the permission from the reporting individual, the incident and what we can learn from it will be compiled into a safety memo for distribution around campus. This will help prevent others from potentially getting hurt or unintentionally causing harm to others! The reporter’s identity will remain anonymous.
Your name and contact information are not required, therefore complete anonymity is possible. If you do choose to enter your personal information, this will help us in learning the root causes of the incident and thereby increase the amount of learning achievable.
Personal Information (optional):
Office or Lab Number
Description of the incident (please be as detailed as possible):
Reporter's opinion of the causes of the incident (both immediate and root causes):
Reporter's opinion as to what preventative measures would help prevent future incidents: