Template

Johansen Near Miss Report

by Ryan Lancaster, from the Community

40+

Use the Johansen Near Miss Report to record and analyze near-miss events before they become incidents. This customizable checklist captures client or site, date and time, preparer, and location, along with a clear description of the event. Classify the type of incident (unsafe act, unsafe condition, act of nature, or third party), assess risk potential by severity and probability, and propose corrective actions. Log witnesses and supporting notes to aid investigation and prevention. Ideal for construction job sites and field operations to improve safety awareness and reduce future risk.

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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
Highmark Near Miss Report Template
This Highmark Near Miss Report template helps teams capture and learn from near miss events before they lead to injuries, equipment damage, or environmental incidents. Record key details including location, description of the event, witnesses, and incident type such as unsafe act, unsafe condition, action of nature, or third-party actions. Evaluate risk by rating severity (major, serious, minor) and probability (frequent, occasional, rare). Add photos, note corrective actions, and use the information to drive preventive measures and improve safety performance across worksites.
by Ryan Lancaster, from the Community
Downloads: 30+
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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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Template
Near Miss and Safety Share Checklist
Use this near miss and safety share template to document incidents and lessons learned across fleet operations. Capture job details, people involved, date and time, location, near-miss type (unsafe act, condition, or equipment), narrative of what happened, supporting photos, and recommendations. Assign corrective actions and a responsible party, record general observations, and share safety insights to prevent future incidents.
by Casey Blackford, from the Community
Downloads: 10+
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Template
Team Industries Near Miss Report
Use this near miss report template from Team Industries to capture and investigate potential incidents before they become injuries. Log employee details, shift, and the department where the event occurred. Classify the event type (hazard ID, unsafe act/behavior, unsafe condition or equipment) and link it to categories such as powered industrial trucks, rigging and cranes, PPE, wagons and trailers, hand and power tools, cutting and grinding, machinery, LOTO, confined space, fall protection, and material handling. Add a detailed description, assign corrective actions, note coaching and follow-up needs, and attach photos. For serious near misses, escalate with a full incident report. Designed for manufacturing operations to strengthen safety culture and compliance.
by TATUM LAUE, from the Community
Downloads: 10+
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Johansen Near Miss Report

About author

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Highmark Near Miss Report Template

Near Miss Report Template

Near Miss and Safety Share Checklist

Team Industries Near Miss Report

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Highmark Near Miss Report Template

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