Near Miss or Safety Concern Reporting Form
See it and fix it if you can, but always report it!
Thank you for submitting a Near Miss or Safety Concern. This form can be used to report any unsafe condition, unsafe act, or any other safety concern you wish to bring to our attention. Proactively reporting these types of incidents helps to prevent future incidents from occurring. The data collected in these forms are used to demonstrate the need for proactive, positive safety changes and will be sent directly to your safety partner.
Please note: If you have had an incident (even if you do not require medical treatment), you MUST complete the
employee injury report
.
Employee Name
Type your name to start the lookup. Choose Anonymous if you wish to submit anonymously.
Department
Enter the department where the Near Miss or Safety Concern is present.
Date of Event
Time of Event
Format Example 06:45am or 12:36 PM
Cause
Please select...
Cut/Scrape
Electrical
Equipment Malfunction/Broken
Exposure
House Keeping
Insect/Animal
Motor Vehicle Accident
Needle Stick
Security
Slip, trip, fall
Strain
Struck by/Against
Other
Near Miss/Safety Concern Discovered
Location
Has the Near Miss/Safety Concern already been corrected?
Please select...
Yes
No
In Progress/Pending
Unknown
Proposed solution or any additional information you wish to provide (please include work order number, if applicable).
To be contacted for additional questions, feedback or resolutions, please enter your email address or phone number.
Attachments
Do you wish to add Files/Attachments?
Please select...
Yes
No
If you have any additional documents or photos to share, please email to
safetyandriskmanagement@fortcollins.gov.
NOTE:
There is a
25 MB per file
size limit, a
35 MB total
file
size limit, and a
10 file limit
per submission.
Please upload any supporting documents, images, invoices, or estimate of damages.
File Upload
To add more than one attachment, select "Add another file". To remove the additional file upload option, select "Remove".
Contact Information