Near miss report form template 2026

1. Click ‘Get Form’ to open the near miss report form template in our editor.
2. Begin by filling in the 'Department' and 'Building' fields to specify where the incident occurred.
3. Indicate the 'Time of Incident' by selecting either am or pm, and provide the exact 'Room #' where the near miss took place.
4. Enter the 'Date of Incident' to document when the event happened.
5. Select your 'Designation' from options such as Faculty, Staff, Student, or Other to identify your role.
6. Check all appropriate conditions that apply to your report, including Near Miss, Safety Concern, Safety Suggestion, or Other.
7. Specify the type of concern by checking Unsafe Act, Unsafe Condition, Unsafe Equipment, Unsafe Use of Equipment, or Other.
8. Thoroughly describe the potential incident/hazard/concern in detail to provide context for your report.
9. (Optional) Fill in your Name and Date Reported along with Contact Information if you wish to be reached for follow-up.
10. Once completed, submit this form electronically through our platform or print it out and send it to EH&S as instructed.

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