1. Required to be completed when you experience a Safety Near Miss in the workplace
2. To be completed in full and emailed to direct manager or the Health & Safety Manager.

Near Miss Defined
OSHA and the National Safety Council defines a near miss as an “unplanned event that did not result in injury, illness or damage – but had the potential to do so.”

Date & Time of Near Miss:
Location of Near Miss. If customer site, please provide address
Select the category the near-miss most relates to:

Describe how the Near Miss occurred (include the body part and type of pain):

Describe what lead up to and caused the Near Miss. Identify root causes:

What was learned and changed due to the Near Miss?

Photo/s that can help explain the what, where, why, or the possible injury:
Name and Signature (optional)
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.