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Near Miss / Hazard Reporting Form

A “Near Miss” is an unplanned event that didn’t result in injury, illness, or death but that had the potential to do so. Although Near Misses cause no immediate harm, they can provide us with useful information to be used to prevent a future accident.

Some examples of Near Misses:

• An employee trips over an extension cord that lies across the floor but avoids a fall by grabbing the corner of a desk.
• An outward-opening door nearly hits a worker who jumps back just in time to avoid a mishap.
• Instead of using a ladder, an employee puts a box on top of a drum, loses balance and stumbles to the ground. Although the employee is shaken, there is no injury.

District employees are encouraged to fill out this form to help make the workplace safer for all employees. The Safety Committee reviews each and every form submission, conducts an investigation, and makes recommendations for safety improvements. 

Employees who have identified a hazard or simply have a suggestion for improving workplace safety are also encouraged to fill out this form, even if they would not categorize the issue as a “Near Miss.”

Please note that this form can be submitted anonymously. In order to ensure you are submitting this form anonymously, please make sure you have logged completely out of the Employee Login section of the portal. Including your name is not required but providing your name will allow the Safety Committee and supervisors to follow up with you regarding additional questions.