Good Catch Submission Form

Good Catch Submission Form

Your safety is our number one priority! Students, faculty, staff, visitors, and contractors are encouraged to report conditions or incidents that they believe could have resulted in more serious consequences, such as personal injury or property damage. Reporting a good catch can allow proper actions to be implemented to help prevent future serious consequences from occurring!

Injuries or Illnesses

If any injury or illness was the result of the incident, please exit this form and complete an Employee Accident Report or contact emergency services.

Any injuries/illness?*

Select

Contact Information

Please provide contact information, unless you wish to remain anonymous.

I wish to remain anonymous.

Please be aware that while anonymous reports are accepted, we do encourage open communication for a more effective resolution process.

Thank you for your understanding and cooperation.

Reporter Name

E-mail Address

Phone Number

Affiliation

Select or enter value

Background Information

Please complete the following fields with as much information as possible.

Date*

Other Location

Setting*

Select

Please describe setting:

Location*

Select or enter value

Is the location a construction zone?

Specific Location*

Please provide exact room numbers and other relevant information pertaining to location.

Incident Information

Please complete the following fields with as much information as possible.

Type of Incident*

How would you describe the incident?

Select

Description of Incident*

Potential Severity*

How would you rate the severity of the incident if no action or follow-up took place? (see below for descriptions)

Catastrophic - Results in death or permanent disability; irreversible environmental damage; closure to business Critical - Results in partial permanent disability, injuries, or illnesses of multiple individuals; reversible environmental damage; violation of law/regulation Marginal - Injury of illness involving in one or more work days lost; mitigable environmental damage where restoration activities can be done Negligible - Minor illness or injury to individuals resulting in one day's absence; does not violate law/regulation; little or no environmental damage

Attachments

Attach any pictures or videos associated with incident.

Drag and drop files here or

Personal Protective Equipment (PPE)

What PPE was being used?

Has the observed incident/risk been mitigated or resolved? If so, what actions were taken to address the issue?*

Please describe what actions were taken to resolve the issue. If no actions were taken, what do you believe should be done to adequately address the issue?

Did you submit a Service2Facilities (S2F) work order to have the issue evaluated/corrected?