Template

A2O Near Miss Report

by William Carter, from the Community

The A2O Near Miss Report is a structured form for recording safety near-miss events so teams can analyze risk and act before injuries occur. Capture date and time, site location, incident description, and select a hazard category such as fall from height, trip on level, fall from equipment, hazardous manual handling, electric shock, caught between, hazardous substance, or falling object. Add photos to clarify what happened, document root causes, note what was learned, and specify corrective and preventive actions or changes implemented. Choose your preferred level of anonymity and sign to attest accuracy. Designed for construction and field operations, the checklist supports safer work practices and continuous improvement.

With SafetyCulture you can

Digitize any process, procedure or policy

Eliminate mistakes made by paper-based processes

Create and share professional reports instantly

Confirm accountability and compliance with a digital log

With SafetyCulture you can

Digitize any process, procedure or policy

Eliminate mistakes made by paper-based processes

Create and share professional reports instantly

Confirm accountability and compliance with a digital log

About author

Community

This community page makes available free workplace checklists and templates created by other users within the SafetyCulture community. SafetyCulture has re-published this content and where possible, has credited the original author. SafetyCulture has not verified the accuracy, reliability or suitability of any community content. You agree that your use of any of this content is in accordance with SafetyCulture’s Terms and Conditions.

Template
K Near Miss Form for Construction Sites
Use this near miss form to standardize reporting on construction sites. Capture company and contractor details, date and time, weather, location, and the category of the near miss such as falls, trips, electric shock, caught between, falling objects, or equipment. Document the description, hazards, affected employees, property damage, and any machinery involved. Identify root causes across equipment, procedures, training, environment, and tools. Assess severity and possible outcomes, record worker statements, and add photos. Define corrective actions, note follow up, and capture lessons learned with name and signature fields.
by Rick Delmonico, from the Community
Downloads: 0
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Template
DRS Near Miss Notification Form
Use this near miss notification form to quickly capture and report workplace safety near miss events. Record date and time, location or customer site, company cell and vehicle number, a clear description of what happened, contributing factors, and what was learned or changed. Attach photos for clarity and sign to confirm accuracy, then email the completed form to the Health and Safety Manager or Claims Manager for follow up.
by Chris Reynolds, from the Community
Downloads: 2,000+
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Template
Near Miss Incident Report Template
Capture and report near miss events before they become incidents. This ready-to-use template guides workers to record when and where a near miss occurred, describe what happened, attach photos, and note immediate actions taken such as isolating an area, tagging out equipment, or notifying a supervisor. Supervisors can log corrective and preventive actions, follow-up activities, and sign-off dates to close the report. Common hazards covered include slips, trips and falls, falls from height or equipment, electrical shock, hazardous substances, manual handling, falling objects, and more. Locations and departments like production, warehousing, maintenance, QA labs, dispatch, and chemical storage are supported, making it ideal for food and beverage manufacturing and other operations.
by Colin Porter, from the Community
Downloads: 30+
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Template
Near Miss Report Form Template
Use this Near Miss Report Form template to capture unplanned events that could have led to injury, illness, environmental harm, or disruption. Based on the IOSH definition, it guides users to record date and time, location, incident category (falls, manual handling, electric shock, hazardous substances, and more), detailed incident description, root causes, lessons learned, and corrective actions. Add supporting photos, capture optional employee details and signatures, and include approvals for closure. Designed for construction and general workplace safety teams to strengthen hazard reporting, analyze trends, and prevent future incidents.
by Chris Skelton, from the Community
Downloads: 0
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A2O Near Miss Report

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K Near Miss Form for Construction Sites

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K Near Miss Form for Construction Sites

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