Title Page

  • Conducted on

  • Prepared by

  • Location
  • 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.”

  • Instructions:
    1. Required to be completed when you experience a Safety or Property Damage Near Miss in the workplace
    2. To be completed in full and emailed to direct to company Safety Director

Where & When

  • Job number

  • Date and Time

Incident/Near Miss Documentation

  • Person(s) involved. Include all company and non-company person(s)

  • What nearly happened - property damage, injury

  • Property damage. Provide details about property involved. Personal, company, or host employer property.

  • A photo will help explain the what, where, why. Upload the photo here:

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

  • What was learned from the near miss?

  • Details of corrective actions or behavior changes action taken

  • A photo will help explain the what, where, why. Upload the photo here:

  • Near injury most relates to:

  • Injury. Provide details about person involved. Limbs, torso, head

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

  • What was learned from the near miss?

  • Details of corrective actions or behavior changes action taken

  • A photo will help explain the what, where, why, or the injury upload the picture here:

Communication

  • Corrections actions or behavior changes were taken to prevent recurrence of near miss or incident

  • Reasoning corrective action was not taken

  • Near miss reported to supervisor. Yes or No

  • Email completed report to company Safety Director

  • Per company policy, promptly notify immediate supervisor. After review with immediate supervisor, revise answer to "yes" and proceed with report.

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.