Near Miss – Unsafe Act – Unsafe Condition Report

UW-MADISON NEAR MISS / UNSAFE ACT / UNSAFE CONDITION REPORT

Download Near Miss Report 1018

NEAR MISS– Near Miss (sometimes described as near hit) describes incidents where no property was damaged and no personal injury sustained, but where, given a slight shift in time or position, damage and/or injury easily could have occurred. This report is intended to help document these situations with the goal of prevention of future similar events. This form can also be used to report general unsafe acts and/or conditions. Anyone of the campus community may complete and submit. It is everyone’s responsibility to report and/or correct these potential accidents/incidents immediately.

The completed report is to be given to one’s supervisor/chair/faculty/building manager or other responsible individual for review and action. If necessary immediate corrective action shall occur to either eliminate the hazard or implement temporarily solutions until long term resolution is completed. This may include writing a work order to Facility Services for repairs. Attach pictures, additional sheets and other documentation if available.

Contact Supervisor for assistance in evaluation of these events. Supervisor may contact Environment, Health and Safety for evaluation assistance as necessary at 608-265-5000.