Report • CampusOptics

This form is designed to report "near miss" incidents. OSHA defines a near miss as an incident in which no property was damaged and no personal injury was sustained, but where, given a slight shift in time or position, damage or injury easily could have occurred.

Thank you for taking the time to report this information as it helps identify challenges with processes and systems. The resolution of these issues can prevent accidents.

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Name* Required

Additional Location Details

Exact Location

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Incident Information

What date and time did the incident occur?

What task was being performed at the time of the incident?

Describe the nature and details of the incident. (Was there equipment or materials being used? Did environmental conditions play a role? If the incident involved a vehicle please indicate who was driving.)

What equipment or materials were being used?

Who was present at the time of the incident? (include email and telephone number for each person)

What factors do you think contributed to the incident?

What steps have been taken to prevent further incidents of the same nature?

Add Supporting Documents

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