Near Miss Reporting Form
OSHA defines a near miss as “an unplanned event that did not result in injury, illness or damage – but had the potential to do so.” A near miss is also referred to as a “close call" or "good catch.”

UCSB employees and students may use this form to report a near miss to Environmental Health & Safety.
EH&S will follow up to determine what corrective actions may be required to prevent a future recurrence.

Reports may be submitted anonymously if desired. Employees are advised that it would be illegal for an employer to take any action against an employee in reprisal for exercising their rights to report safety issues.

If you encounter problems submitting the form online, you can download a PDF version of the hazard reporting form (http://www.ehs.ucsb.edu/files/docs/ii/Hazard_report_form.pdf) and submit information on the near miss by campus mail (mail code 5132) or fax (805.893.8659).

Description of near miss: *
Your answer
Location: *
Your answer
Suggestion for improving safety:
Your answer
Has this matter been reported to your supervisor?
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