Lumiform / Templates / Near Miss Incident Report

Near Miss Incident Report

It’s important to document close calls, so they can be analyzed to prevent a similar occurrence from happening again in the future. After an incident report is filled out, it must be submitted to HR for review. Write down the date and time of the near-miss incident, the events that lead up to it, and corrective actions or recommendations. This report might just save lives.

Downloaded 19 times

★ ★ ★ ★ ★

Rated 5/5 stars on Capterra

Say goodbye to paper checklists!

Lumiform enables you to conduct digital inspections via app easier than ever before

Cut inspection time by 50%
Uncover more issues and solve them 4x faster
Select from over 5,000 expert-proofed templates

Digitalize this paper form now

Cut inspection time by 50%
Uncover more issues and solve them 4x faster
Select from over 4000 expert-proofed templates

★ ★ ★ ★ ★

Rated 5/5 stars on Capterra

Near Miss Incident Report

Audit

Near Miss Report

A near miss is a potential hazard or incident that has not resulted in any personal injury. Unsafe working conditions, unsafe employee habits, improper use of equipment or use of malfunctioning equipment have the potential to cause work related injuries. It is everyone's responsibility to report and/ or correct these potential accidents/incidents immediately. Please complete this form as a means to report these near-miss situations.

Department/ Location

Time of incident

Please write all that apply: Unsafe Act, Unsafe Condition, Unsafe Equipment, Unsafe use of Equipment

Description of incident or potential hazard:

Picture of Incident

Employee Signature & Date

Near Miss Investigation

Description of the near-miss condition:

Causes (primary & contributing)

Corrective action taken (remove the hazard, replace, repair, or retrain in the proper procedures for the task)

Signature & Date

Management

Previous template

Next template

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.