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Fill out this form to report a Near Miss. Once complete be sure to hit the COMPLETE button and email the form to your direct manager or the Health & Safety Manager.
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Free 1,000+ Workplace Checklists & Templates created by the SafetyCulture team.
A near miss is an unplanned event that threatens human safety or health, the environment, or the continued normal operation of the business enterprise, wherein the last protective barrier is challenged, but defeated. Use this near miss form to report a near miss incident.
Use this near miss form to quickly record the incident and indicate of work stopped or continued business as usual.
This near miss template allows providing the description and photos surrounding the incident as well as inclusion of the names of other witnesses of the near miss.
Based on the Incident Investigation Form provided by OSHA in their Incident Investigation Guide for Employers, this digital near miss form can be used to do the following: 1) Preserve or document the scene, 2) Collect information, 3) Determine root causes, 4) Implement corrective actions.
