The University of Texas Medical Branch

Occupational Safety and Fire Prevention

Near-Miss Hazard Report Form

The Near-Miss Hazard Report form only applies to building and grounds located on the Galveston Texas campus. 

Concerns with offsite facilities are to be reported to the offsite facility manager.

Exact location where "near miss" occurred or hazard exists:

 

Describe the nature and circumstances around the "near miss" or hazard:

 

Would you like EHS to contact you about this?        

If so, please fill in your contact information below:

 

First Name:   

 

Last Name:   

 

Department:  

 

Route No.:   

 

Phone ext:   

 

E-mail address:   

 

01/09/2009

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