Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Near Miss Report Form

  • Name of the person making this report

  • Employee Number

  • Name of the person directly involved in the incident if different

  • Employee Number

  • You may leave this section blank & submit the report anonymously but this may impair the reviewers ability to make effective judgements or recommendations.

Incident Details

  • Incident date & time

  • Location

  • Precise nature of the near miss event

  • In your view what could have be done to prevent a reoccurrence?

  • Witness details

  • Estimate risk for potential injury or accident damage

  • Has this near miss been reported to line management, customer or site operator?

  • If yes who?

  • Signed

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.