Report • CampusOptics

The purpose of this form is to document incidents and near misses that do not involve injuries.

A near-miss is defined as a potential hazard or 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. Near misses also may be referred to as close calls, near accidents, or injury-free events.

For the purpose of this report form, an incident is defined as an unplanned, undesired event that adversely affects completion of a task. Incidents may include property or equipment damage.

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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Basic Information

Department* Required

Supervisor or PI In Charge of Space or Personnel* Required

Date of Event* Required

Time of Event* Required

Witnesses

Date of Investigation

Incident Information

Type of Event

PPE worn at time of event

Summary of What Occurred* Required

Site Observations* Required

Other Information* Required

Cause(s) of Incident:* Required

Follow-up actions taken/required (For completed actions, list the date completed and for future actions, list the estimated date of completion)* Required

Lessons Learned* Required

Add Supporting Documents

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