Templates
Quick Near Miss Form

Quick Near Miss Form

Use this form for near misses to quickly record the incident and allow you to stop or continue working.

Use this template
or download pdf
Quick Near Miss Form

Use this form for near misses to quickly record the incident and allow you to stop or continue working.

Use this template
or download pdf

Categories

  • Health and safety management templates
  • Risk management and compliance templates
  • General templates
  • Manufacturing templates
  • Emergency preparedness templates
  • Incident management templates
  • Workplace safety templates
Preview of the template
Audit
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.”
Location of Near Miss. If customer site, please provide address
Date & Time of Near Miss:
Photo/s that can help explain the near miss:
Please explain the near miss that occurred:
Stop work or work business as usual?
Name and Signature (optional)
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This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.