Accident and Near Miss Reporting Form

Name of Person(s) involved

Person(s) Phone Number

Was the person classified as a full-time or part-time employee at the time of the injury, including student employment positions?

Yes

Incident Date and Time

Name of Principle Investigator or Supervisor or Not Applicable N/A

Department

Location or Building and Room Number

Witness Name

Witness Phone Number

Was this an Accident?

Was this a Near Miss?

Was the person transported off site For Treatment?

Yes, if Yes where

Were there any injuries?

if yes, type of injury

Please describe incident

Is there a Standard Operating Procedure?

Is there a specific training in place?

*Required fields

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