Template

Checklist para Operadores de Infraestructura

by Chris Skelton, from the Community

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.

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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 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
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Template
BAIE Near Miss Notification Form
This Near Miss Notification Form helps teams capture and report events that could have resulted in injury, illness, or damage but did not. Based on OSHA’s near-miss definition, the template guides users to record date and time, exact location, detailed descriptions, and contributing factors. It includes selectable categories such as falls from height, trips or same-level falls, electric shock, hazardous substances, falling objects, and more, enabling faster analysis and corrective action. Use this checklist to standardize reporting, strengthen hazard awareness, and improve safety performance across construction sites and similar work environments.
by Sarah Hollister, from the Community
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Template
Near Miss Incident Report Form
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.
by Matthew Oneill, from the Community
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Template
Near Miss Template
This near miss report template helps teams capture and share important details about unplanned events that could have caused harm. Based on OSHA and National Safety Council guidance, it prompts workers to record the date and time, location, a clear description of what happened, and add photos if available. It also includes fields for witnesses, employee details, and a signature, with instructions to email the report to a direct manager or Health and Safety Manager. Use this template to improve hazard awareness, enable timely corrective actions, and prevent future incidents. Templates in the Public Library are examples only; always seek professional advice to ensure suitability for your workplace and jurisdiction.
by Andrea Boccabella, from the Community
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Checklist para Operadores de Infraestructura

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