Report • CampusOptics

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Name* Required

Additional Location Details

Exact Location

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Date of incident

Time of incident

Department/Area

Reported by (Name and Contact Information)

Supervisor of person reporting incident (if applicable)

Did the near miss incident involve equipment?

If yes, what equipment was involved?

Was any hazardous material involved?

If yes, what hazardous material was involved?

Was there a risk of injury?

Was there a risk of property damage?

Was the area well-lit?

Was the area clean and free of obstructions?

Was weather a factor?

If yes, how was the weather a factor?

Did you take any immediate actions to prevent an incident?

If yes, what actions were taken to prevent an incident?

Was the area secured after the near-miss?

Was human error a factor?

If yes, what human error was a factor?

Were safety procedures followed?

Describe safety procedures followed if applicable

Were there any witnesses to the near miss?

Name and contact information for witnesses

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