Report • CampusOptics

Near miss reporting helps EH&S 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 mitigate the hazard, and to share the lessons learned with the university community.

If you have any questions please call 901-678-5700.

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Name* Required

Additional Location Details

Exact Location

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Personal Information

Name* Required

Date* Required

Phone Number* Required

Email* Required

Description of Near Miss

Describe what happened?* Required

What acts or conditions led directly to the incident?* Required

What corrective actions have/will be taken to prevent a similar incident, if applicable?* Required

Getting it Resolved

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

Expected Completion Date

Add Supporting Documents

Add files to upload as supporting documentation along with your incident.