Incident Report • CampusOptics

This form should be used for shop safety concerns including machine guarding, hazardous energy control and power tool safety.

Reporter Info

Email* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Campus, Building, or Outdoor Area* Required

Additional Location Details

Exact Location

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Basic Information

Department

Affiliation

Occurred At

Concern Description

Describe the nature of the safety concern or hazard encountered?

Were proper machine guarding measures in place and functional at the time of the incident or concern?

Did the incident or safety concern involve hazardous energy sources ( electrical, mechanical, thermal, chemical) and was energy control (lockout/tagout) properly implemented?

Were there any injuries or near misses associated with the safety concern?

Add Supporting Documents

Add files to upload as supporting documentation along with your incident report.