Hazard/Near Miss Report

Hazard/Near Miss

Type of Report *

Hazard

Near Miss

I Wish to Remain Anonymous:

Yes

*By checking this box any personal contact information that is required (email, etc) will be kept anonymous as remedial actions are taken.

Reported By: *

Email Address: *

University Affiliation: *

Faculty/Staff

Student

Visitor

Building: *

Room: *

Phone Number: *

Level of Safety Concern: *

Description of Safety Concern: *

Have you reported this before?

Yes

To whom? *

Other Comments:

reCAPTCHA

If you are human, leave this field blank.

View All Forms