Lab Near Miss Form

Date of Near Miss(Required)

Which Department/Research Group is associated with the lab location?(Required)

Building and Room Number where the near miss occurred.(Required)

Select the primary type of near miss/unsafe condition observed:(Required)

Describe the near miss or unsafe condition in detail. What happened, what was the potential outcome, and what was the outcome avoided?(Required)

What immediate action, if any, did you or others take to mitigate the hazard after the near miss?(Required)

Do you have any suggestions for corrective actions to prevent recurrence?(Required)

If, Yes, please provide your preferred contact method (Email, Phone, etc.) and information:

Environmental Health & Safety