Free Near Miss Report Template

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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 reportcheck mark
    The job title of the person completing the incident reportcheck mark
    Their mobile phone numbercheck mark
    The email address of the employee responsiblecheck mark
    That person’s residential addresscheck mark
    The supervisor on shift at the time of the near misscheck mark
    Details of what happened with the Near Misscheck mark
    The date of the near misscheck mark
    Time of near misscheck mark
    A description of the exact location of the incidentcheck mark
    A description of what the employee was doing at the timecheck mark
    A detailed description of the steps taken up to the point this happeningcheck mark
    The opinion of the staff member as to what should be changed to help stop this from happening again.check mark
    If they seemed medical assistance, these details should be recorded.check mark

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.

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