• Accident - Incident - Near Miss
    Investigation Form

  • Audit Title

  • Document No.

  • Project

  • Project number

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • Who was involved?

  • Reported to Supervisor?


  • Date

  • Time

  • Immediate or direct causes.
    Immediate direct causes of accidents/incidents may be attributed to substandard practices or substandard conditions. Immediate direct causes are symptoms of deeper problems.

    Substandard Practices
    - Is "any departure from an accepted, normal, or correct procedure or practice that permits the occurrence of an accident/incident."

    Substandard condition
    - Is "any hazardous arrangement which, if left uncorrected, may lead to an accident/incident."

  • What was the immediate or direct cause?

  • Underlying or indirect causes.

    The following maybe used as a guide:
    - Worker unsuitable for assignment
    - Lack of adequate training
    - Safe job procedure not developed
    - Safe job procedure not followed or enforced
    - Safety equipment not provided
    - Lack of proper instruction
    - Deliberate disregard for safety regulation
    - Lack of regular safety inspection
    - Hazards not recognized
    - Lack of maintenance system
    - Lack of a lock out system
    - Substandard design
    - Use of drugs / alcohol

  • What were the underlying or indirect causes?

  • Was a hazard assessment done?

  • Why was a hazard assessment not completed?

  • Did the hazard assessment recognize the hazard?

  • Was training given for the task?

  • Describe the training worker received for assigned task.

  • Explain why training was not given.

  • Was instructions provided before the near miss?

  • What instructions have been provided?

  • Explain why training was not given.

  • Were cautions given?

  • What cautions were given?

  • Explain why training was not given.

Prevention and Recommendations

  • How can similar scenarios be prevented in the future?

  • Recommendations for further action

  • Recommendations completed by:

  • When will the recommendations be completed?

Accident - Incident - Near Miss Scene

  • Tap for picture of scene

  • Drawing not to scale
    North ^

  • Tap to draw the scene

Sign off

  • Worker

  • Supervisor

  • Reviewed by senior management.

  • Date:

  • Comments or recommendations.

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.