1300 W. Park Street | Butte, MT 59701 | mtech.edu | 406.496.4463
Report of Unsafe or Unhealthful Working Conditions or
a Near Miss Incident
This form is provided for the assistance of employees at Montana Tech and is not
intended to constitute the only method by which a report may be submitted.
Briefly describe the near miss incident or the hazard which exists, including the approximate number of
employees and students exposed or threatened by this hazard.
Location of unsafe or unhealthful condition or near miss incident. Please be as specific as possible.
Does this hazard immediately threaten death or serious physical harm or property environmental
Do you have any suggestions for corrective actions that could eliminate this hazard, or if it was a near
miss, actions that could prevent it from happening again?
Is this the first time this hazard or near miss has been reported? YES NO UNSURE
If this has previously been reported, when was it reported and to whom?
Name of person reporting condition (optional)
Date of incident or hazard recognition:
Phone #
Name of person responding to report:
Date of response:
Action taken:
Send form to EH&S when completed.
A near miss is defined as an incident that has the potential to cause serious injury or property damage. The
incident reveals a physical condition or employee action that could lead to future serious injury or property
damage if not corrected.