Near Miss Incident Report

The Near Miss Incident Report Template can be used to document potential workplace hazards or incidents that could have turned into workplace accidents. While OSHA Occupational Safety and Health Administration, does not require near-miss reporting, it is a valuable safety management practice that helps to prevent injuries and accidents.

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Health & Safety
Near Miss Incident Report

General Information

Details Of Person Reporting

Incident Details

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Checklist by GoAudits.com – Please note that this checklist is intended as an example. We do not guarantee compliance with the laws applicable to your territory or industry. You should seek professional advice to determine how this checklist should be adapted to your workplace or jurisdiction.

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Near Miss Incident Report

1. Date and time of the Incident.

2. Location (please be as accurate as possible).

1. First Name

2. Surname

3. Category of Person – staff, student, contractor or visitor

4. If other, give more details

5. Name of the contractor (if applicable)

1. Description of the Incident

2. Describe what happened?

3. What immediate actions were taken at the time?

4. List additional actions which could be taken to prevent a similar occurrence?

5. Photograph(s) of the area and/or results of the near-miss or incident

6. Additional comments / observations

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