Reporting Injuries and Incidents : University of Dayton, Ohio

Incident and Near-Miss Reporting Form

An incident is when something happened that caused harm or damage; a near-miss is when something happened, but no harm or damage was caused. University employees, students and others (volunteers, visitors, etc.) should use this form to report an incident or near-miss.

Non-employees should also use this form to report an injury. University employees (including student employees) should report all illnesses or injuries to HR using the Employee Illness and Injury Report, located in Porches.

This form will be sent to Environmental Health and Safety and is a confidential report.

Type of Report

Date and Time of Incident or Near-Miss

Full Name

Phone Number

Status or Affiliation

Name of Person Reporting the Incident or Near-Miss (if different than above)

Email or Phone Number of Person Reporting the Incident or Near-Miss (if different than above)

Status/Affiliation of Person Reporting the Incident or Near-Miss (if different than above)

Location of Incident or Near-Miss

Describe the Incident or Near-Miss

If reporting an injury, please describe the injury and any treatment provided (leave blank if no injury occurred)

If reporting property or vehicle damage, please describe the damage (leave blank if no damage occurred)