Information

  • Type of incident

  • Name of Employee preparing the report

  • Location

  • Employee Type

  • Employee / person associated with the near miss / incident

Reporting

  • Date & Time of Near Miss / Incident

  • System or Equipment name related to the near miss

  • Were there any witnesses?

  • Enter Names

  • Select the category the near-miss most relates to:

  • Describe how the Near Miss occurred

  • Photo/s that can help explain the what, where, why, or the possible injury:

  • If possible, identify any root cause(s):

  • Signature of employee associated to the near miss

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.