Template

Near Miss Incident Report Form

by Matthew Oneill, from the Community

This near miss form helps teams quickly document unplanned events that could have caused injury, illness, or damage. Capture the location, date and time, photos, and a clear description of what happened, and indicate whether work stopped or continued. Include optional employee name and signature for accountability, then submit to your Health and Safety Manager or Supervisor. Ideal for improving workplace safety and incident reporting across job sites.

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.

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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
Get

Quick Near Miss Form

Use this near miss form to quickly record the incident and indicate of work stopped or continued business as usual.

by SafetyCulture

300+

Get

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

2,000+

Get

Template

Modebest Near Miss and Unsafe Observation Report

Use this free Modebest Near Miss and Unsafe Observation Report to document unplanned events that could have caused harm on construction sites. Capture report number, date and time, location, detailed description, and add optional photos. Record witnesses, define near miss per OSHA guidance, and include the reporter’s name and signature. Use as part of site safety practices and email to the contract manager and Health and Safety department.

by Michael Gleese, from the Community

20+

Get

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

Get

Near Miss Incident Report Form

About author

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Quick Near Miss Form

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Quick Near Miss Form

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