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 firstname.lastname@example.org. All information provided will be kept confidential and is for University purposes only.
QUESTIONS or COMMENTS?
Contact EH&S at (585) 275-3241 or e-mail EH&S Questions.
This page last updated 10/8/2015. Disclaimer.