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 conditions (e.g., unsafe acts, equipment defect, etc.) 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." Identifying such a situation represents a "Good Catch" that just might save you or a co-worker from injury! 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
Contact information not required for anonymous reporting.
Near-miss/Close call Incident Details
Date of Near-miss *
Time of Near-miss
:
be as specific as possible
Describe what happened