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University Of Rochester

Employee Near Miss Form

GOOD NEWS! The format and method for submitting Employee Near Miss Reports will be improved in late January 2018. Stay tuned for additional information!

NOTE: This form is NOT to be used to report actual incidents or injuries that have occurred. If you or one of your employees experiences an incident or injury please complete an Employee Incident/Injury Report.

INSTRUCTIONS:  A near miss is an unplanned event that did not result in injury, illness, or damage - but had the potential to do so. We ask that all Employee Near Miss Reports are submitted with 24 hours of the occurrence. Employees are also encouraged to review the incident with their co-workers and collectively agree on how to reduce the potential hazard.

Please fill out all applicable sections. If you have any questions, please contact Environmental Health & Safety at 275-3241 or by email at questions@safety.rochester.edu. All information provided will be kept confidential and is for University purposes only.

Employee Information:

Employee Name:

Occupation:

Department:   

Employee Work Phone Number:

Employee E-mail Address:

Near Miss Event Information:

Date and Time of Event (i.e. 11/14/14 8:30 am):

Location of Near Miss (Building/Room):

Type of Location (Please check all that apply)

Corridor Laboratory / Research
Mechanical Space Office Setting
Parking Lot Patient Care
Public Setting Vivarium
Walkway (Exterior) Other

  • What task were you performing when this event occurred?
  • What personal protective equipment was in use at the time of the potential incident?
  • What injury might you have sustained if the incident actually occurred?
  • What steps could be taken in the future to reduce this potential hazard?

Additional Information:

Please add any other pertinent information concerning this Near Miss:

Please list any additional issues or concerns:
Please check here if you wish this report be kept confidential


Confidentiality: All information provided will be kept confidential upon request and is for University purposes only. If you have concerns, please refer to the University's Policy 108 on Confidentiality (http://www.rochester.edu/working/hr/policies/pdfpolicies/108.pdf) as well as the Code of Conduct for Business Activities (http://www.rochester.edu/working/codeofconduct/IId.html).

Once you have submitted this form, a confirmation page will appear. If you do not see this confirmation page, please contact the EH&S main office at 275-3241. In order to track down the problem, we will need to know your location, type of computer and Internet browser that you are using. Thank you.

If you are unable to submit this form online, simply print out the pdf version of this page - Near Miss Report Form - and write in your responses for each question. Please print legibly. Fax the completed form to EH&S at 274-0001.


QUESTIONS or COMMENTS?
Contact EH&S at (585) 275-3241 or e-mail EH&S Questions.

This page last updated 10/8/2015. Disclaimer.