Safety Yellow Cards

Use this form to report near misses.

Type of Incident

	Near miss (potential for loss)	Minor injury (first aid)	Minor property damage (under $1,000)
Please select the type of incident you are reporting

Reported by: First and Last Name

Date of incident

Time of Incident

Location of Incident

Description of Incident

Corrective Action

I would like feedback regarding my report (If yes, please check the box.)

Please note: More severe incidents are to be reported directly to your supervisor immediately, or after medical treatment.

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Environmental Health and Safety