University of Memphis Near Miss Report
Environmental Health & Safety

Near Miss Reporting helps track unsafe acts or unsafe conditions before an injury or illness occurs. This form is used to formally document the recognition of a hazard, the changes made to prevent a recurrence of the hazard, and to share the lessons learned with the University Community. Instructions for filling out the Near Miss form can be found here.

All information is required.

Person Reporting: Today's Date: 04/18/2021
Phone Number: Email:

Description of the near miss
Who was involved in the near miss? Where did it occur? When did it occur? What happened? How did it occur?
What acts or conditions led directly to the incident?


Severity (If the incident had evolved into an accident, please rank the severity of the resulting accident):
(low) 1 2 3 4 (high) 5

Potential for Recurrence (Please rank the level of probability that a similar incident could occur if unaddressed):
(low) 1 2 3 4 (high) 5

What corrective actions have/will be taken to prevent a similar incident?

Who is responsible for taking these actions and following up to see that they are complete?


Expected Completion Date: Actual Completion Date:

 

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