Incident Report • CampusOptics

Reporter Info

Email* Required

Phone Number* Required

First Name* Required

Last Name* Required

Campus, Building, or Outdoor Area* Required

Additional Location Details

Exact Location

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Date of incident* Required

Time of incident* Required

Department/Area* Required

Reported by (Name and Contact Information)* Required

Supervisor of person reporting incident (if applicable)* Required

Did the near miss incident involve equipment?* Required

If yes, what equipment was involved?* Required

Was any hazardous material involved?* Required

If yes, what hazardous material was involved?* Required

Was there a risk of injury?* Required

Was there a risk of property damage?* Required

Was the area well-lit?* Required

Was the area clean and free of obstructions?* Required

Was weather a factor?* Required

If yes, how was the weather a factor?* Required

Did you take any immediate actions to prevent an incident?* Required

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

Was the area secured after the near-miss?* Required

Was human error a factor?* Required

If yes, what human error was a factor?* Required

Were safety procedures followed?* Required

Describe safety procedures followed if applicable* Required

Were there any witnesses to the near miss?* Required

Name and contact information for witnesses* Required

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