Near-Miss/Close Call Incident Reporting Form

A near miss is an incident where no property was damaged and no personal injury sustained, but where, given a slight shift in time or position, damage and/or injury or illness easily could have occurred. It can be thought of as a "close call." EHS encourages reporting of near-miss/close call incidents so that contributing factors can be identified and abated before they result in personal injury/illness or property damage. By reporting these circumstances you are contributing to a safer and healthier campus environment. We appreciate your participation and assure you that there is no risk of repercussions for reporting a situation or hazard.

Contact Information
Near-miss/Close call Incident Details
Date of Near-miss *
Time of Near-miss
:
be as specific as possible
Describe what happened