Report • CampusOptics

Near Miss Reporting is the process of identifying and preventing an unsafe act or unsafe condition before it causes an injury or illness. This form is used to formally document the recognition of a hazard, the change that is made to prevent a reoccurrence of the hazard and create and possibly use certain information submitted to educate the University community on safety practices to prevent injuries. Personal information shared on this online form will NOT be shared to the University community.

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Anonymous Submission

This submission will be anonymous. No reporter information will be collected, but all of your responses and form information will be submitted.

Location

Name* Required

Additional Location Details

Exact Location

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Online form

Near Miss Date* Required

Near Miss Time* Required

Who was involved in the near miss?

What exactly happened?

Supervisor Name* Required

Supervisor email address* Required

Supervisor Contact Number* Required

Describe the near miss that occurred* Required

Add Supporting Documents

Add files to upload as supporting documentation along with your incident.