Form Center

2. Please use this form to report near-misses and assist us in preventing future incidents and making the City of Dubuque a safer workplace. This report can be submitted anonymously.
   A near-miss is a potential hazard or incident that has not resulted in any personal injury or property damage. Some examples of near-misses are unsafe conditions, improper use of equipment, use of faulty equipment, not following proper procedures, etc. It is everyone's responsibility to report and correct any of these potential hazards immediately.
4. For questions or cases deemed immediately dangerous to life or death, notify supervisor and call Human Resources at 563-589-4125. In case of an emergency, dial 911.
6. Department*
7. Building
8. Other Area
10. Date and Time of Incident*
    Date and Time of Incident

    Date and Time of Incident
11. Mark all appropriate conditions*

    1. Near-miss
    2. Safety concern
    3. Safety suggestion
    4. Other (please describe)
12. Please describe "Other"
14. Type of Concern*

    1. Unsafe act
    2. Unsafe condition of area
    3. Unsafe condition of equipment
    4. Unsafe use of equipment
    5. Other (please describe)
15. Please describe "Other"
17. Describe the potential incident/hazard/concern and possible outcome, in as much detail as possible:*
19. Upload a photo if available
20. Additional photo
22. Safety suggestion
24. Name (optional)
25. Phone number (optional)
27. Email address (optional)
28. Today's date
    Today's date
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field