Report • CampusOptics

THANK YOU FOR MAKING SAFETY A PRIORITY!

Safety Hazard: Any condition posing a danger to faculty, staff, students, or visitors or a condition that could result in damage to University property, the property of others, or the environment.

Near Miss: An unplanned event that did not result in injury, illness, or damage, but had the potential to do so. Only a fortunate break in the chain of events prevented an injury, fatality, or damage from occurring.

Complete the following information when it is believed a safety hazard exists or a near miss has occurred. Contact information, though optional, is helpful in the event additional information is needed.

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Anonymous Submission

This submission will be anonymous. No reporter information will be collected, but all of your responses and form information will be submitted.

Location

Name* Required

Additional Location Details

Exact Location

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Information

Classification of person reporting safety hazard/near miss* Required

Date safety hazard/near miss was witnessed* Required

Time safety hazard/near miss was observed* Required

Campus where safety hazard/near miss observation was observed* Required

What near miss/safety hazard category was observed

Behavioral

Unsafe condition(s)

Other

Indicate potential incident type of safety hazard/near miss* Required

Life/Health

Property

Environment

Other

Indicate severity of potential impact(s) to Life, Property and/or Environment as applicable* Required

Describe Safety Hazard or Near Miss* Required

Describe Potential Impact(s) - What could go wrong?* Required

What corrective actions have been or should be taken to remove/reduce the hazard or the likelihood of recurrence?* Required

Add Supporting Documents

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