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Near-Miss Incident Report Form Template

Efficiently document and analyze near-miss incidents

Ignoring near misses can lead to severe accidents or injuries in the workplace. This Near-Miss Incident Report Form Template helps safety teams document potential hazards and track trends effectively. By using this template, you can improve workplace safety culture, ensure compliance with safety regulations, and facilitate proactive incident analysis, ultimately minimizing future risks. Explore how this template can streamline your reporting process today.

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Full name (optional if anonymous)
Email (optional)
Do you wish to remain anonymous?
Yes
No
Date of near-miss
Exact location (site and area)
Was a supervisor notified?
Yes
No
Environment conditions at the time
Describe what happened (facts only, avoid identifying information unless necessary)
Names or roles of others involved (if any)
Are photos or videos available for this near-miss?
Yes
No
Not applicable
Hazard type(s) involved
Please Specify:
Primary immediate cause
Please Specify:
Was required PPE in use?
Yes
No
Not applicable
Were there any injuries?
Yes
No
Unknown
Potential severity if the near-miss had resulted in an incident
Insignificant
Minor
Moderate
Major
Severe/Catastrophic
Unknown
If repeated, how likely is it that this near-miss could result in harm?
0 Not at all likely
1
2
3
4
5 Extremely likely
Immediate actions taken
Removed or controlled hazard
Isolated area or restricted access
Shut down equipment
Cleaned spill or debris
Applied lockout/tagout
Reported to supervisor
Posted signage or barriers
None
Other
Please Specify:
Recommended corrective or preventive actions
Is follow-up required?
Yes
No
May we contact you if clarification is needed?
Yes
No
Enter your name as signature
Signature date
I affirm the information provided is accurate to the best of my knowledge.
Yes
No
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Paper art illustration depicting a near-miss incident report form for FormCreatorAI article.

When to use this form

Use this form right after a close call at work: a forklift clipped a rack, a tool sparked near solvents, or a guest tripped but did not fall. It helps employees, supervisors, and safety leads capture facts while they are fresh, so you can fix hazards before someone gets hurt. Include it in toolbox talks and daily operations across warehouses, hospitals, hotels, and offices. For events with an actual injury, route the case to the Employee accident report form. If the close call involved smoke, alarms, or extinguishers, pair it with the Fire call report sheet form. Consistent reporting builds a record you can trend and share to prevent repeats.

Must Ask Near-Miss Incident Report Questions

  1. What happened, and what harm was narrowly avoided?

    This clarifies the event and the realistic worst case, which guides risk rating and urgency. Clear detail helps your safety team choose the right controls, from barriers to training.

  2. Where and when did it occur?

    Location, date, and shift identify hotspots and time-based patterns. This makes it easier to plan inspections and schedule fixes when affected teams are on site.

  3. What task, equipment, and conditions were present?

    Knowing the task, tools, PPE, weather, lighting, or housekeeping reveals contributing factors. Maintenance can act faster when model numbers or serials are included.

  4. Who was involved, and who was notified?

    Names and roles enable follow-up and coaching, and witnesses help verify facts. For issues that involve HR or conduct, escalate with the Staff incident report form.

  5. What immediate actions and longer-term fixes do you recommend?

    Documenting temporary controls and suggested changes encourages ownership and speeds approvals. It also records what to audit later to confirm the risk is gone.

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