Near Miss Report Form

Keep your workplace safe by learning from close calls with our Near Miss Report Form. Designed for frontline workers, supervisors, and HSE officers, this template provides a structured, repeatable way to capture incidents that almost resulted in injury, damage, or environmental harm.

Reporting near misses is essential for identifying hidden hazards, strengthening controls, and preventing serious accidents. This form guides users through all key sections so nothing important is missed.

What is included

Cover Page:

• Site, department, reporter, and supervisor details
• Clear safety disclaimer to support health and safety requirements

Near Miss Details:

• Event date, time, and exact location
• Work activity being performed at the time
• Description of what happened and how the near miss occurred
• Persons involved and witnesses
• Potential consequences and severity rating
• Unsafe acts, unsafe conditions, and initial root cause observations

Corrective Actions:

• Action description and rationale
• Responsible person and target completion date
• Actual completion date and status
• Follow-up or effectiveness notes

Investigation Summary & Sign Off:

• Investigation summary fields
• Reporter and supervisor sign-off

Using this template allows you to:

• Standardise near miss reporting across projects and teams
• Quickly identify and address hazards before they lead to incidents
• Track corrective actions and follow-ups through to closure
• Maintain accurate records for audits, investigations, and continuous improvement
• Build a strong learning culture around workplace safety

Disclaimer: This template is provided as a guidance tool only. All near miss events must be managed in accordance with your organisation’s procedures and local health and safety regulations. We do not accept responsibility for how this form is used.

Download the Near Miss Report Form today to encourage early hazard reporting, prevent repeat incidents, and strengthen your safety culture.