Near-Miss/Close Call Incident Reporting Form

EHS and the Chancellor's University Safety Committee encourages reporting of near-miss/close call incidents and potentially unsafe practices in the workplace so that contributing factors can be identified and abated before they result in personal injury/illness or property damage. 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." By reporting these circumstances you are contributing to a safer and healthier campus environment. Information reported is shared throughout the University for educational/awareness purposes; specific identifying information (e.g., names, departments, etc.) is redacted. 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