SCHOOLS INSURANCE PROGRAM FOR EMPLOYEES (SIPE) - Resources

REPORT A NEAR HIT / CLOSE CALL

A near miss is an unplanned event that did not result in injury, illness, or damage, but had the potential to do so. Recognizing and reporting near miss incidents can make a major difference to the safety of workers within the district. Thank you for your concern and together we can achieve a safer and healthier work environment.

Required fields are denoted with *.

District Name*:

Your Name (you may remain anonymous):

Names of employee(s) involved:

Date of incident*:

Time of incident*:

Please check all appropriate conditions*: Unsafe Act Unsafe Condition Unsafe Equipment Unsafe use of Equipment Please select at least one condition.

Was a student involved?*: Yes No Please select yes or no.

In your opinion, what is the probability of re-occurrence?*: High Medium Low Please select probability.

Description of incident or situation*:

Recommended corrective action*:

Supervisor's Name*:

Supervisor's Email Address*:

Confirm Supervisor's Email Address*:

Send a copy to:

Important Note: Some school districts filter their emails for spam. Make sure your district's spam filter will accept email from safetyreport@slosipe.org.