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Laboratory Near-Miss Report Form

Complete this form to report near misses in the Chemistry Department. This form can be used to report unsafe actions by anyone in the department, report unsafe situations, or report scenarios that given different events could have resulted in an emergency.

Reports will be reviewed by the Department Safety Officer and these reports can be made anonymously.

This field is NOT required. Near misses can be reported anonymously.
This field is NOT required.
This field is NOT required.
Please indicate where the near miss occurred or where the safety issue is present. (Be specific as possible)

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