OSHA Near Miss Form

• Site conducted

  Select

• Company Name:

• Date:

  Date

• Prepared By:

• Role or Position in the Company:

• Name of affected employee:

• Their role or position in the company:

• Date and time when the near miss occurred:

  Date
• Site/location of the near miss:
  Address

• Where exactly in the site/location did the near miss occur? (the specific area, room, floor, or building)

• What hazard/s triggered the near miss?

• Detailed description of the near miss: Include relevant events leading up to, during, and after the near miss. This information should come from the affected employee.

• To add a photo or image related to the near miss, click the "Photo" icon at the bottom right:

  Yes

  No

  N/A

• Names of eye witnesses:

• Their role/s or position/s in the company:

• Description of the near miss from eye witnesses: Include relevant events leading up to, during, and after the near miss.

• Names of employees who were in the specific area, room, floor, or building at the time of the near miss, but did not see the near miss occur (yet were aware that it was happening):

• Their role/s or position/s in the company:

• Description of the near miss from these employees: Include relevant events leading up to, during, and after the near miss.

Identifying Root Causes

• What caused or allowed the near miss to happen?

• What were the specific factors?

• Factors that contributed to the near miss were found in which areas? Select all that apply.

  Select Equipment Procedures Training Environment Tools

  • Equipment
  • Procedures
  • Training
  • Environment
  • Tools

• Was a machine or safety device in use during the near miss?

  Yes

  No

  Unsure

• Did the machine have a defect?

  Yes

  No

  N/A

• At the time of the near miss, was anyone aware that the machine had a defect?

  Yes

  No

  N/A

• Did the person/s inform the safety officer on-site or a supervisor?

  Yes

  No

  N/A

• Was the machine malfunctioning when the near miss occurred?

  Yes

  No

  N/A

• What caused the machine to malfunction?

• Did the safety device fail?

  Yes

  No

  N/A

• Why did it fail?

• Were safety procedures being followed?

  Yes

  No

  N/A

• Why were they not being followed?

Recommended Corrective Action

• To create a corrective action, click the "Action" icon at the bottom right:

  Yes

  No

  N/A

Follow-Up / Completion

• List of root causes addressed or corrective actions taken:

• Name and Signature:

  Sign