Free Near Miss Report Template
This Downloadable Template Is Part Of Our Free DIY Company Health And Safety Program Collection
A near miss should be treated as seriously as a real incident.
Your company can use our free template to keep a record of each one and use them to investigate the root cause of the problem.
The Fillable PDF template can be downloaded below. We hope this helps you in implementing an effective workplace health and safety system!
The Team At SINC
A Near Miss Form Should Include:
The full name of person filling in the near miss report![check mark](data:image/svg+xml;base64,PHN2ZyB4bWxucz0iaHR0cDovL3d3dy53My5vcmcvMjAwMC9zdmciIHdpZHRoPSIyOCIgaGVpZ2h0PSIyOCIgdmlld0JveD0iMCAwIDI4IDI4Ij48ZyBmaWxsPSJub25lIiBzdHJva2U9IiM1ZjZkN2MiIHN0cm9rZS13aWR0aD0iMiI+PHJlY3Qgd2lkdGg9IjI4IiBoZWlnaHQ9IjI4IiByeD0iNiIgc3Ryb2tlPSJub25lIi8+PHJlY3QgeD0iMSIgeT0iMSIgd2lkdGg9IjI2IiBoZWlnaHQ9IjI2IiByeD0iNSIgZmlsbD0ibm9uZSIvPjwvZz48L3N2Zz4=)
The job title of the person completing the incident report![check mark](data:image/svg+xml;base64,PHN2ZyB4bWxucz0iaHR0cDovL3d3dy53My5vcmcvMjAwMC9zdmciIHdpZHRoPSIyOCIgaGVpZ2h0PSIyOCIgdmlld0JveD0iMCAwIDI4IDI4Ij48ZyBmaWxsPSJub25lIiBzdHJva2U9IiM1ZjZkN2MiIHN0cm9rZS13aWR0aD0iMiI+PHJlY3Qgd2lkdGg9IjI4IiBoZWlnaHQ9IjI4IiByeD0iNiIgc3Ryb2tlPSJub25lIi8+PHJlY3QgeD0iMSIgeT0iMSIgd2lkdGg9IjI2IiBoZWlnaHQ9IjI2IiByeD0iNSIgZmlsbD0ibm9uZSIvPjwvZz48L3N2Zz4=)
Their mobile phone number![check mark](data:image/svg+xml;base64,PHN2ZyB4bWxucz0iaHR0cDovL3d3dy53My5vcmcvMjAwMC9zdmciIHdpZHRoPSIyOCIgaGVpZ2h0PSIyOCIgdmlld0JveD0iMCAwIDI4IDI4Ij48ZyBmaWxsPSJub25lIiBzdHJva2U9IiM1ZjZkN2MiIHN0cm9rZS13aWR0aD0iMiI+PHJlY3Qgd2lkdGg9IjI4IiBoZWlnaHQ9IjI4IiByeD0iNiIgc3Ryb2tlPSJub25lIi8+PHJlY3QgeD0iMSIgeT0iMSIgd2lkdGg9IjI2IiBoZWlnaHQ9IjI2IiByeD0iNSIgZmlsbD0ibm9uZSIvPjwvZz48L3N2Zz4=)
The email address of the employee responsible![check mark](data:image/svg+xml;base64,PHN2ZyB4bWxucz0iaHR0cDovL3d3dy53My5vcmcvMjAwMC9zdmciIHdpZHRoPSIyOCIgaGVpZ2h0PSIyOCIgdmlld0JveD0iMCAwIDI4IDI4Ij48ZyBmaWxsPSJub25lIiBzdHJva2U9IiM1ZjZkN2MiIHN0cm9rZS13aWR0aD0iMiI+PHJlY3Qgd2lkdGg9IjI4IiBoZWlnaHQ9IjI4IiByeD0iNiIgc3Ryb2tlPSJub25lIi8+PHJlY3QgeD0iMSIgeT0iMSIgd2lkdGg9IjI2IiBoZWlnaHQ9IjI2IiByeD0iNSIgZmlsbD0ibm9uZSIvPjwvZz48L3N2Zz4=)
That person’s residential address![check mark](data:image/svg+xml;base64,PHN2ZyB4bWxucz0iaHR0cDovL3d3dy53My5vcmcvMjAwMC9zdmciIHdpZHRoPSIyOCIgaGVpZ2h0PSIyOCIgdmlld0JveD0iMCAwIDI4IDI4Ij48ZyBmaWxsPSJub25lIiBzdHJva2U9IiM1ZjZkN2MiIHN0cm9rZS13aWR0aD0iMiI+PHJlY3Qgd2lkdGg9IjI4IiBoZWlnaHQ9IjI4IiByeD0iNiIgc3Ryb2tlPSJub25lIi8+PHJlY3QgeD0iMSIgeT0iMSIgd2lkdGg9IjI2IiBoZWlnaHQ9IjI2IiByeD0iNSIgZmlsbD0ibm9uZSIvPjwvZz48L3N2Zz4=)
The supervisor on shift at the time of the near miss![check mark](data:image/svg+xml;base64,PHN2ZyB4bWxucz0iaHR0cDovL3d3dy53My5vcmcvMjAwMC9zdmciIHdpZHRoPSIyOCIgaGVpZ2h0PSIyOCIgdmlld0JveD0iMCAwIDI4IDI4Ij48ZyBmaWxsPSJub25lIiBzdHJva2U9IiM1ZjZkN2MiIHN0cm9rZS13aWR0aD0iMiI+PHJlY3Qgd2lkdGg9IjI4IiBoZWlnaHQ9IjI4IiByeD0iNiIgc3Ryb2tlPSJub25lIi8+PHJlY3QgeD0iMSIgeT0iMSIgd2lkdGg9IjI2IiBoZWlnaHQ9IjI2IiByeD0iNSIgZmlsbD0ibm9uZSIvPjwvZz48L3N2Zz4=)
Details of what happened with the Near Miss![check mark](data:image/svg+xml;base64,PHN2ZyB4bWxucz0iaHR0cDovL3d3dy53My5vcmcvMjAwMC9zdmciIHdpZHRoPSIyOCIgaGVpZ2h0PSIyOCIgdmlld0JveD0iMCAwIDI4IDI4Ij48ZyBmaWxsPSJub25lIiBzdHJva2U9IiM1ZjZkN2MiIHN0cm9rZS13aWR0aD0iMiI+PHJlY3Qgd2lkdGg9IjI4IiBoZWlnaHQ9IjI4IiByeD0iNiIgc3Ryb2tlPSJub25lIi8+PHJlY3QgeD0iMSIgeT0iMSIgd2lkdGg9IjI2IiBoZWlnaHQ9IjI2IiByeD0iNSIgZmlsbD0ibm9uZSIvPjwvZz48L3N2Zz4=)
The date of the near miss![check mark](data:image/svg+xml;base64,PHN2ZyB4bWxucz0iaHR0cDovL3d3dy53My5vcmcvMjAwMC9zdmciIHdpZHRoPSIyOCIgaGVpZ2h0PSIyOCIgdmlld0JveD0iMCAwIDI4IDI4Ij48ZyBmaWxsPSJub25lIiBzdHJva2U9IiM1ZjZkN2MiIHN0cm9rZS13aWR0aD0iMiI+PHJlY3Qgd2lkdGg9IjI4IiBoZWlnaHQ9IjI4IiByeD0iNiIgc3Ryb2tlPSJub25lIi8+PHJlY3QgeD0iMSIgeT0iMSIgd2lkdGg9IjI2IiBoZWlnaHQ9IjI2IiByeD0iNSIgZmlsbD0ibm9uZSIvPjwvZz48L3N2Zz4=)
Time of near miss![check mark](data:image/svg+xml;base64,PHN2ZyB4bWxucz0iaHR0cDovL3d3dy53My5vcmcvMjAwMC9zdmciIHdpZHRoPSIyOCIgaGVpZ2h0PSIyOCIgdmlld0JveD0iMCAwIDI4IDI4Ij48ZyBmaWxsPSJub25lIiBzdHJva2U9IiM1ZjZkN2MiIHN0cm9rZS13aWR0aD0iMiI+PHJlY3Qgd2lkdGg9IjI4IiBoZWlnaHQ9IjI4IiByeD0iNiIgc3Ryb2tlPSJub25lIi8+PHJlY3QgeD0iMSIgeT0iMSIgd2lkdGg9IjI2IiBoZWlnaHQ9IjI2IiByeD0iNSIgZmlsbD0ibm9uZSIvPjwvZz48L3N2Zz4=)
A description of the exact location of the incident![check mark](data:image/svg+xml;base64,PHN2ZyB4bWxucz0iaHR0cDovL3d3dy53My5vcmcvMjAwMC9zdmciIHdpZHRoPSIyOCIgaGVpZ2h0PSIyOCIgdmlld0JveD0iMCAwIDI4IDI4Ij48ZyBmaWxsPSJub25lIiBzdHJva2U9IiM1ZjZkN2MiIHN0cm9rZS13aWR0aD0iMiI+PHJlY3Qgd2lkdGg9IjI4IiBoZWlnaHQ9IjI4IiByeD0iNiIgc3Ryb2tlPSJub25lIi8+PHJlY3QgeD0iMSIgeT0iMSIgd2lkdGg9IjI2IiBoZWlnaHQ9IjI2IiByeD0iNSIgZmlsbD0ibm9uZSIvPjwvZz48L3N2Zz4=)
A description of what the employee was doing at the time![check mark](data:image/svg+xml;base64,PHN2ZyB4bWxucz0iaHR0cDovL3d3dy53My5vcmcvMjAwMC9zdmciIHdpZHRoPSIyOCIgaGVpZ2h0PSIyOCIgdmlld0JveD0iMCAwIDI4IDI4Ij48ZyBmaWxsPSJub25lIiBzdHJva2U9IiM1ZjZkN2MiIHN0cm9rZS13aWR0aD0iMiI+PHJlY3Qgd2lkdGg9IjI4IiBoZWlnaHQ9IjI4IiByeD0iNiIgc3Ryb2tlPSJub25lIi8+PHJlY3QgeD0iMSIgeT0iMSIgd2lkdGg9IjI2IiBoZWlnaHQ9IjI2IiByeD0iNSIgZmlsbD0ibm9uZSIvPjwvZz48L3N2Zz4=)
A detailed description of the steps taken up to the point this happening![check mark](data:image/svg+xml;base64,PHN2ZyB4bWxucz0iaHR0cDovL3d3dy53My5vcmcvMjAwMC9zdmciIHdpZHRoPSIyOCIgaGVpZ2h0PSIyOCIgdmlld0JveD0iMCAwIDI4IDI4Ij48ZyBmaWxsPSJub25lIiBzdHJva2U9IiM1ZjZkN2MiIHN0cm9rZS13aWR0aD0iMiI+PHJlY3Qgd2lkdGg9IjI4IiBoZWlnaHQ9IjI4IiByeD0iNiIgc3Ryb2tlPSJub25lIi8+PHJlY3QgeD0iMSIgeT0iMSIgd2lkdGg9IjI2IiBoZWlnaHQ9IjI2IiByeD0iNSIgZmlsbD0ibm9uZSIvPjwvZz48L3N2Zz4=)
The opinion of the staff member as to what should be changed to help stop this from happening again.![check mark](data:image/svg+xml;base64,PHN2ZyB4bWxucz0iaHR0cDovL3d3dy53My5vcmcvMjAwMC9zdmciIHdpZHRoPSIyOCIgaGVpZ2h0PSIyOCIgdmlld0JveD0iMCAwIDI4IDI4Ij48ZyBmaWxsPSJub25lIiBzdHJva2U9IiM1ZjZkN2MiIHN0cm9rZS13aWR0aD0iMiI+PHJlY3Qgd2lkdGg9IjI4IiBoZWlnaHQ9IjI4IiByeD0iNiIgc3Ryb2tlPSJub25lIi8+PHJlY3QgeD0iMSIgeT0iMSIgd2lkdGg9IjI2IiBoZWlnaHQ9IjI2IiByeD0iNSIgZmlsbD0ibm9uZSIvPjwvZz48L3N2Zz4=)
If they seemed medical assistance, these details should be recorded.![check mark](data:image/svg+xml;base64,PHN2ZyB4bWxucz0iaHR0cDovL3d3dy53My5vcmcvMjAwMC9zdmciIHdpZHRoPSIyOCIgaGVpZ2h0PSIyOCIgdmlld0JveD0iMCAwIDI4IDI4Ij48ZyBmaWxsPSJub25lIiBzdHJva2U9IiM1ZjZkN2MiIHN0cm9rZS13aWR0aD0iMiI+PHJlY3Qgd2lkdGg9IjI4IiBoZWlnaHQ9IjI4IiByeD0iNiIgc3Ryb2tlPSJub25lIi8+PHJlY3QgeD0iMSIgeT0iMSIgd2lkdGg9IjI2IiBoZWlnaHQ9IjI2IiByeD0iNSIgZmlsbD0ibm9uZSIvPjwvZz48L3N2Zz4=)
This sample resource is provided to you free by SINC BUSINESS CORPORATION to help with your compliance efforts and includes no warranty as to its suitability for any particular task. It is only our opinion based on our experience and should not be considered legal advice.