Free Near Miss Report Template

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.

Near Miss PDF Template

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

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    A Near Miss Form Should Include

  • The full name of person filling in the near miss report
  • The job title of the person completing the incident report
  • Their mobile phone number
  • The email address of the employee responsible
  • That person’s residential address
  • The supervisor on shift at the time of the near miss
  • Details of what happened with the Near Miss
  • The date of the near miss
  • Time of near miss
  • A description of the exact location of the incident
  • A description of what the employee was doing at the time
  • A detailed description of the steps taken up to the point this happening
  • The opinion of the staff member as to what should be changed to help stop this from happening again.
  • If they seemed medical assistance, these details should be recorded.

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This sample resource is provided to you free by SINC LIMITED 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.