Title Page

  • Site conducted

  • Company Name:

  • Date:

  • Prepared By:

  • Role or Position in the Company:

OSHA Near Miss Form

  • Name of affected employee:

  • Their role or position in the company:

  • Date and time when the near miss occurred:

  • Site/location of the near miss:
  • 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:

  • 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.

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

  • Did the machine have a defect?

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

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

  • Was the machine malfunctioning when the near miss occurred?

  • What caused the machine to malfunction?

  • Did the safety device fail?

  • Why did it fail?

  • Were safety procedures being followed?

  • Why were they not being followed?

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

Follow-Up / Completion

  • List of root causes addressed or corrective actions taken:

  • Name and Signature:

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.