UNMC Near-Miss / Potential Hazard Reporting Form

Date: 06/09/2023

Nebraska Medicine employee incidents and all incidents involving patients must be reported through RL Reporting System.

* Your First Name

* Your Last Name

* Department:

* Building:

* Room:

* Phone Number:

* E-Mail Address

* Supervisor:

* Date of Near-Miss / Observation:

* Time of Near-Miss / Observation:

Name anyone else that witnessed the incident:

* Please provide a brief description of the near-miss / potential hazard: *all incidents involving patients must be reported on the RL System.

Type the text from the image into the space below.

Why...

University of Nebraska Medical Center

42nd and Emile, Omaha, NE 68198

402-559-4000|Contact Us

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