Near-Miss Form

Near-Miss Reporting

A near-miss is any unplanned event that did not cause serious injury or damage, but had the potential to do so. Use this form to report any safety or accident near-misses you have recently experienced or witnessed.

The purpose of this reporting system is to collect information that can be used to help the entire department perform chemistry more safely. The near-misses reported here are not meant to blame individuals, but to provide examples of "lessons learned" for everyone's benefit. The details of a near-miss situation may be shared with staff, faculty, and students as part of a training session. You may report anonymously or leave your contact info for follow-up from Cindy Hodge

* Required

The near-miss I'm reporting here relates to:
Teaching Activity Near-miss
Which Class?
Contact Information
You may leave your name and email address here, and Alison Redden will contact you for follow-up.
Supporting Documents
Are you uploading supporting documents?
CAPTCHA
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.