Near-Miss Report Form

A near-miss is a potential hazard or incident that has not resulted in any personal injury or property damage. Some example of near-misses are unsafe conditions, improper use of equipment,use of faulty equipment, not following proper procedures.
It is everyone's responsibility to report and correct any of these potential hazards immediately. Please use this form to report near-misses and assist us in preventing future incidents.

Department: *

Building: *

Room: *

Date of Incident: *

Time of Incident: *

Mark all appropriate conditions: *

Near-miss Safety concern Safety suggestion Other (describe)

Other:

Type of concern: *

Unsafe act Unsafe condition of area Unsafe condition of equipment Unsafe use of equipment Other (describe)

Other:

Describe the potential incident/hazard/concern and possible outcome (in as much detail as possible): *

Safety Suggestions: *

Name:

Date Reported:

Phone Number:

Email Address:

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