Accident and Near Miss Reporting Form
Please use this form to report accidents or near misses so that we can all learn from one another's experiences. We ask for contact information just in case we need more details or someone has questions. When the event is shared with the department individual and group names will not be included.
Supervisor's Name
Your answer
Reporting individual's name
Your answer
Reporting individual's email address
Your answer
Please provide details about the incident. What went wrong?
Your answer
Describe what lessons were learned. What could be done differently to prevent a similar accident?
Your answer
Submit
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