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Instructions:
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)

Near Miss Report Form Checklist

Created by: SafetyCulture Staff | Industry: General | Downloads: 184

A near miss is an unplanned event that threatens human safety or health, the environment, or the continued normal operation of the business enterprise, wherein the last protective barrier is challenged, but defeated. Use this near miss form to report a near miss incident.

Signup for a free iAuditor account to download and edit this checklist. It will be added to your free account and you will be able to conduct inspections from your mobile device.

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Audit

Instructions:
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)