APA/AIE Near Miss or Incident Reporting Form information - Please read first

This form is meant to collect information on near misses or incidents to start discussions that will raise awareness. A near miss is an unplanned event that did not result in injury, illness, or damage - but had the potential to do so. The form is designed to keep the filer anonymous. You are welcome to add any older event that you think will help others. We encourage you to listen during safety meetings or any other utility interactions/communications for any incidents that count as learning events and could be reported on this form. The information submitted on this form will help all of us learn from each other and aid our safety mission.

Date and Time

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Type of Work

Job Description

Logistical Information

Cause of Incident

Other information

It is recommended that employees are informed of steps taken to avoid repeating the near miss situation.