Safety Hazard
Any condition posing a danger to faculty, staff, students, or visitors or a condition that could result in damage to University property, the property of others, or the environment.
Near Miss
An unplanned event that did not result in injury, illness, or damage, but had the potential to do so. Only a fortunate break in the chain of events prevented an injury, fatality, or damage from occurring.
Complete the following information when it is believed a safety hazard exists or a near miss has occurred. Contact information, though optional, is helpful in the event additional information is needed. Clicking "Submit" forwards this report to Florida Tech's EH&S via email.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
What is your affiliation with Florida Tech?
Please Select
Faculty
Student
Staff
Visitor
Contractor/Vendor
Other
If other, please specify:
Date and Time of Safety Hazard or Near Miss Observed
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Safety Hazard or Near Miss (Building & Room or Other Location)
Describe Safety Hazard or Near Miss (Who, What, Why, How):
Describe Potential Impact(s):
Indicate severity of potential impact(s) to Life, Property, and/or the Environment, as applicable:
Rows
Major
Moderate
Minor
Life/Health
Property
Environment
What corrective actions have been or should be taken to reduce the hazard or the likelihood of recurrence?
Would you like a summary of your responses?
Yes
No
Submit
Should be Empty: