Template

C and W Near Miss Reporting Form

by Kent Walton, from the Community

30+

This near miss reporting form enables workers to document potential incidents before harm occurs. Capture detailed location information, select consequence categories such as safety, property, environmental, quality, or equipment, and describe the condition, likely impacts, root causes, and suggested corrective actions. Supervisors can assign action items with owners and due dates, sign off, and share with EHS for tracking and follow up to strengthen hazard prevention and continuous improvement across the site.

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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
Near Miss Reporting Template
Use this Near Miss Reporting template to document potential hazards and incidents that did not result in injury. Capture audit details, site, department, date and time, who was involved, and whether it involved an unsafe act, condition, or equipment. Describe the near-miss, outline primary and contributing causes, and record corrective actions such as removing hazards, repairing or replacing equipment, or retraining staff. Include management sign-off to close the loop. Standardize near-miss investigations to reduce risk, strengthen safety culture, and prevent future incidents across operations.
by Danny White, from the Community
Downloads: 10+
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Template
HSE Near Miss Report Template
This HSE Near Miss Report template helps teams log and analyze near-miss incidents to prevent future harm. Record site, date, observer, and document number, then describe the hazardous act or condition observed. Note whether the issue was corrected, identify root causes, and document corrective actions taken. Indicate if further investigation is required and finalize with a sign-off by the QHSE Manager. Designed to support proactive safety and environmental protection across operations, this template facilitates consistent reporting and action tracking to reduce injuries, illness, and environmental impact.
by Longinus Ike, from the Community
Downloads: 0
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Template
Near-Miss/Incident Form
Form for reporting near misses or incidents on site
by Mark Taylor, from the Community
Downloads: 60+
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Template
Near Miss Report Template
This Near Miss Report template helps construction teams quickly capture and investigate near-miss events before they cause harm. Record key details such as document number, client or site, date and time, location, personnel, and department. Identify factors including unsafe acts, unsafe conditions, unsafe equipment, or improper equipment use. Describe the incident or hazard, attach photos, and capture employee signatures and dates. The investigation section guides users to document the near-miss condition, identify primary and contributing causes, and define corrective actions such as removing hazards, replacing or repairing equipment, or retraining staff. Includes management sign-off to close the loop and improve site safety and HSE compliance.
by Chris Graydon, from the Community
Downloads: 0
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Near Miss Reporting Template

Use this Near Miss Reporting template to document potential hazards and incidents that did not result in injury. Capture audit details, site, department, date and time, who was involved, and whether it involved an unsafe act, condition, or equipment. Describe the near-miss, outline primary and contributing causes, and record corrective actions such as removing hazards, repairing or replacing equipment, or retraining staff. Include management sign-off to close the loop. Standardize near-miss investigations to reduce risk, strengthen safety culture, and prevent future incidents across operations.

by Danny White, from the Community

10+

Get

Template

HSE Near Miss Report Template

This HSE Near Miss Report template helps teams log and analyze near-miss incidents to prevent future harm. Record site, date, observer, and document number, then describe the hazardous act or condition observed. Note whether the issue was corrected, identify root causes, and document corrective actions taken. Indicate if further investigation is required and finalize with a sign-off by the QHSE Manager. Designed to support proactive safety and environmental protection across operations, this template facilitates consistent reporting and action tracking to reduce injuries, illness, and environmental impact.

by Longinus Ike, from the Community

Get

Template

Near-Miss/Incident Form

Form for reporting near misses or incidents on site

by Mark Taylor, from the Community

60+

Get

Template

Near Miss Report Template

This Near Miss Report template helps construction teams quickly capture and investigate near-miss events before they cause harm. Record key details such as document number, client or site, date and time, location, personnel, and department. Identify factors including unsafe acts, unsafe conditions, unsafe equipment, or improper equipment use. Describe the incident or hazard, attach photos, and capture employee signatures and dates. The investigation section guides users to document the near-miss condition, identify primary and contributing causes, and define corrective actions such as removing hazards, replacing or repairing equipment, or retraining staff. Includes management sign-off to close the loop and improve site safety and HSE compliance.

by Chris Graydon, from the Community

Get

C and W Near Miss Reporting Form

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