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Near Miss Report Form

You can use this Near Miss Template to report a near-miss incident.
A near miss is an accident that endangers human safety or health, the environment, or the proceeded normal operation of the business enterprise, wherein the last protective barrier is challenged, but defeated.

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Near Miss Defiition OSHA defines a near miss as an incident in which no property was damaged and no personal injury was sustained, but where, given a slight shift in time or position, damage or injury easily could have occurred.

Date & Time of Near Miss:

Exact location of Near Miss:

Select the category the near-miss most relates to::

Describe how the Near Miss occurred (including the body part and type of pain):

Describe what lead to the Near Miss. Identify root causes:

What was learned and changed due to the Near Miss?

Photo/s that support explaining the what, where, why, or the possible injury:

Name and Signature (optional):

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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.

Near Miss Report Form

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