Form Center

2. Instructions

   The near miss report helps Facilites track and learn from near misses that could potentially harm employees or members of the public. Please report safety hazards or near misses and provide as much detail as you can. 

4. Incident Date*
   Incident Date

   Incident Date
6. Department
   -- Select One --AssesorAutditorCentral ServicesClerks OfficeCommissionersCoronerDevelopment ServicesDistrict CourtHealth DistrictHuman ResourcesRenewSheriffPublic DefensePublic WorksSuperior CourtTreasurerWSUYouth Services
8. Name*
9. Email Address*
11. Phone Number
13. Location Of Incident (be specific)
15. Describe What Happened (or hazard)
17. Name(s) of Witnesses (if any)
19. Could Injury/Hazard Have Been Prevented?
Leave This Blank:


20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

* indicates a required field