Hazard / Near-Miss Report

Employee-reported hazard or near-miss capture. The leading-indicator form that proactive safety programs depend on — you can prevent the incident that hasn't happened yet.

Report Type

• What are you reporting?
• Is there an immediate danger right now?
  If yes, stop work if safe to do so and notify a supervisor or emergency response process immediately.
• Brief summary of the hazard or near-miss
  Describe what happened or what is unsafe. Keep it factual and specific.

Location and Timing

• Date observed
• Time observed
• Location type
• Specific location
  Provide the building, area, room, line, aisle, equipment, or other location detail needed to find the issue.

Hazard Details

• Hazard category
• Describe the hazard or unsafe condition
• Approximate number of people exposed
  Enter a count if known. Use the minimum necessary information.
• How often does this occur?

Near-Miss Event Details

• What could have happened?
• Describe the near-miss event

Immediate Controls

• Was work stopped or the area isolated?
• Immediate actions taken
• What additional controls are needed?

Reporter and Follow-Up

• Your name
  Optional. Leave blank for anonymous submission.
• Your email
  Optional. Used only for follow-up questions or status updates.
• Your phone number
  Optional. Provide only if you prefer phone follow-up.
• Preferred follow-up method
• I consent to be contacted about this report if I provide contact information
  By providing contact details, you agree they will be used only for safety follow-up and corrective action communication.