Near-Miss Report

To ensure the most effective resolution of the issue, please complete all fields of the form with the utmost accuracy and thoroughness. The form also allows for anonymous reporting, ensuring the confidentiality of the information provided.

EVENT DATE *

DEPARTMENT AREA

WHAT HAPPENED (Brief description to help understand the issue)? *

HOW MANY PEOPLE were involved in the event?

What KIND OF INJURY could have happened?

SUGGESTIONS ON HOW TO HANDLE THE CASE to prevent it from happening again *

NAME of the person who made this report (optional)

Upload any photos and/or other documentation

I agree to the processing of my data (View policy) *

Reporting a Near Miss