Template

Near Miss Incident Report Template

by Colin Porter, from the Community

30+

Capture and report near miss events before they become incidents. This ready-to-use template guides workers to record when and where a near miss occurred, describe what happened, attach photos, and note immediate actions taken such as isolating an area, tagging out equipment, or notifying a supervisor. Supervisors can log corrective and preventive actions, follow-up activities, and sign-off dates to close the report. Common hazards covered include slips, trips and falls, falls from height or equipment, electrical shock, hazardous substances, manual handling, falling objects, and more. Locations and departments like production, warehousing, maintenance, QA labs, dispatch, and chemical storage are supported, making it ideal for food and beverage manufacturing and other operations.

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.

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
Get
Template
Near Miss and Risk Observation Report
Use this Near Miss and Risk Observation Report template to capture close calls and hazards before they cause harm. Record the site, date, location, reference number, and a brief description of the event. Rate severity on a 1–10 scale before and after immediate corrective actions. Cover common risk areas including falling objects, slips, trips and falls, housekeeping, restricted access, working at height, PPE, manual handling, lifting operations, confined space, excavations, environment, plant and equipment, vehicles, utilities, and other hazards. Include exact location and actions taken to make the area safe. Reporters may submit their name or remain anonymous to encourage prompt reporting and continuous improvement in site safety.
by lis burrow, from the Community
Downloads: 0
Get
Template
A2O Near Miss Report
The A2O Near Miss Report is a structured form for recording safety near-miss events so teams can analyze risk and act before injuries occur. Capture date and time, site location, incident description, and select a hazard category such as fall from height, trip on level, fall from equipment, hazardous manual handling, electric shock, caught between, hazardous substance, or falling object. Add photos to clarify what happened, document root causes, note what was learned, and specify corrective and preventive actions or changes implemented. Choose your preferred level of anonymity and sign to attest accuracy. Designed for construction and field operations, the checklist supports safer work practices and continuous improvement.
by William Carter, from the Community
Downloads: 0
Get
Template
K Near Miss Form for Construction Sites
Use this near miss form to standardize reporting on construction sites. Capture company and contractor details, date and time, weather, location, and the category of the near miss such as falls, trips, electric shock, caught between, falling objects, or equipment. Document the description, hazards, affected employees, property damage, and any machinery involved. Identify root causes across equipment, procedures, training, environment, and tools. Assess severity and possible outcomes, record worker statements, and add photos. Define corrective actions, note follow up, and capture lessons learned with name and signature fields.
by Rick Delmonico, from the Community
Downloads: 0
Get

Near Miss Incident Report Template

About author

You might also like

Near Miss Report Template

Near Miss and Risk Observation Report

A2O Near Miss Report

K Near Miss Form for Construction Sites

You might also like

Near Miss Report Template

Near Miss and Risk Observation Report

A2O Near Miss Report

K Near Miss Form for Construction Sites