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Near Miss Notification Form

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Instructions: 1. Required to be completed when you experience a Safety Near Miss in the workplace 2. To be completed in full and emailed to direct manager or the Health & Safety Manager.
Near Miss Defined OSHA and the National Safety Council defines a near miss as an “unplanned event that did not result in injury, illness or damage – but had the potential to do so.”
Date & Time of Near Miss:
Location of Near Miss. If customers site, please provide address
Select the category the near-miss most relates to:
Describe how the Near Miss occurred (include the body part and type of pain):
Describe what lead up to and caused the Near Miss. Identify root causes:
What was learned and changed due to the Near Miss?
If a photo will help explain the what, where, why, or the injury upload the picture here:
Choose your level of anonymity for this near miss report
By my signature below I attest that the information I have provided is true and accurate to the best of my knowledge:
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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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