USF Incident and Near Miss Reporting Form

The Incident & Near Miss Reporting form should be used to report any incident that occurs within the USF System. An incident means any unplanned event that causes, or has the potential to cause, an injury or illness and/or damage to equipment, buildings, or the natural environment. This also includes near misses when there is potential for an injury or illness.

If an accident or incident resulted in a work-related injury or illness, your supervisor must be contacted immediately. Please proceed to the Workers' Compensation website for more information on how to report a work-related injury or illness.

Please fill out the online Incident and Near Miss Reporting form below and submit to Environmental Health & Safety within 24 hours of the incident. Due to medical privacy concerns, no personal identifying information of the person involved in the incident shall be entered or submitted with the form.

* Indicates required fields

Preparer's Full Name *

Preparer's Phone Number *

Preparer's Email Address *

Witness Name (optional)

Witness Phone Number

Scene of Near Miss or Incident *

If 'Other', please indicate

Date of Incident *

Time of Incident *

Location of Incident (Building/ Room if applicable) *

What type of report are you submitting? *

Near Miss Report

Describe the unsafe condition or near miss. * Required if you selected 'Near Miss'

Please suggest what can be done to avoid similar occurrences. * Required if you selected 'Near Miss'

Incident Report

How did the incident happen? Who or what was involved? * Required if you selected 'Incident'

Describe the injury or illness. Describe the damage to equipment or the environment. * Required if you selected 'Incident'

Describe what happened after the incident. * Required if you selected 'Incident'

Describe what medical treatment, cleanup, or equipment repair was necessary. * Required if you selected 'Incident'

What emergency personnel were contacted? * Required if you selected 'Incident'

Please suggest any corrective actions that could be taken to prevent the incident from happening again. * Required if you selected 'Incident'

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