Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Anonymous Near-Miss Report

  1. 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.
  2. 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.
  3. Mark all appropriate conditions*
  4. Type of Concern*
  5. Leave This Blank:

  6. This field is not part of the form submission.