Lumiform Mobile audits & inspections
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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.

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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
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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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