Template

Near Miss and High Potential Reporting

by Danny White, from the Community

This Near Miss and High Potential Reporting template helps teams document potential incidents that did not result in injury but indicate risk. Capture event details, date and time, people involved, and whether it was an unsafe act, condition, or equipment issue. Record causes, corrective actions such as removing hazards, repairs, or retraining, and secure management sign-off. Use it to standardize reporting and strengthen safety and compliance across worksites.

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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
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
Envirotrol Near Miss Report
Use this Envirotrol Near Miss Report template to quickly document potential hazards and incidents that did not result in injury. Record the location, time, department, classification, likely injuries and causes, attach photos, note root causes, and log corrective actions taken. Capture signatures to confirm completion and accountability. Designed for construction and field operations to improve reporting, prevent accidents, and strengthen workplace safety.
by Aaron Brookins, from the Community
Downloads: 10+
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Template
ICS Near Miss/Hit Investigation Template
Use this ICS Near Miss and Hit Investigation template to document jobsite incidents that did not result in injury or damage but had the potential to do so. Capture jobsite name or number, date and time, employees involved, preparer, and location. Record a clear narrative of the event, identify root causes, and specify corrective or disciplinary actions to prevent recurrence. Note any training required or retraining for personnel and add comments for additional context. This structured checklist supports consistent reporting, accountability, and continuous improvement across construction sites and crews.
by Corey Crosby, from the Community
Downloads: 0
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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

Envirotrol Near Miss Report

Use this Envirotrol Near Miss Report template to quickly document potential hazards and incidents that did not result in injury. Record the location, time, department, classification, likely injuries and causes, attach photos, note root causes, and log corrective actions taken. Capture signatures to confirm completion and accountability. Designed for construction and field operations to improve reporting, prevent accidents, and strengthen workplace safety.

by Aaron Brookins, from the Community

10+

Get

Template

ICS Near Miss/Hit Investigation Template

Use this ICS Near Miss and Hit Investigation template to document jobsite incidents that did not result in injury or damage but had the potential to do so. Capture jobsite name or number, date and time, employees involved, preparer, and location. Record a clear narrative of the event, identify root causes, and specify corrective or disciplinary actions to prevent recurrence. Note any training required or retraining for personnel and add comments for additional context. This structured checklist supports consistent reporting, accountability, and continuous improvement across construction sites and crews.

by Corey Crosby, from the Community

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

Near Miss and High Potential Reporting

About author

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Near Miss Reporting Template

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Near Miss Reporting Template

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