Near Miss / Safety Concern Reporting Form

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Please correct the field(s) marked in red below:

“See it and fix it if you can, but always report it!

Reporting near misses and safety concerns prevents injuries from occurring, and is an important aspect of the safety culture within Poudre Fire Authority. Employees are encouraged to take ownership of near misses and safety concerns."

1

Date & Time of Event (Optional)

2
Reported By / Your Name (Optional)
3

Details of Near Miss/Safety Concern Discovered

4

Optional Attachment for details of the Near Miss/Safety Concern

5

Specific Location/Item to be Addressed

6

Optional Attachment for location/item to be addressed

7

Has concern already been resolved?

Has concern already been resolved?
8
If no, what is your suggested solution?
9

Optional Attachment for suggested solution

10
Do you want to be contacted for more information?
Do you want to be contacted for more information?
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