Near Miss Report Form
Document Control Company: [COMPANY NAME] · Logo: [COMPANY LOGO] · Address: [COMPANY ADDRESS] Prepared by: [RESPONSIBLE PERSON] · Date: [DATE] · Approved by (signature): _________________
| Field | Value |
|---|---|
| Category | Incident and Near Miss Reporting |
| Recommended Industry | All |
| Document Type | Report |
| Access Level | Starter |
| Last Reviewed | 2026-06-29 |
| Last Updated | 2026-06-29 |
How to Use This Template
Complete the fields as fully and accurately as possible at the time of the task or event. Route the completed document per your internal process and retain it with your records.
Template Body
A near miss is a close call with no injury — reporting it helps fix the cause. Reporting is encouraged and not disciplined.
| Field | Entry |
|---|---|
| Date / time: | [____] |
| Location: | [____] |
| Reported by: | [NAME] (optional/anonymous allowed) |
| What almost happened: | [____] |
| What could the outcome have been: | [____] |
| Contributing conditions: | [____] |
| Immediate action taken: | [____] |
| Suggested fix: | [____] |