Near Miss Incident Report

Updated: over a week ago

Near Miss Incident Report

General Information

1. Date and time of the Incident.


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


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Details Of Person Reporting

1. First Name


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


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4. If other, give more details


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5. Name of the contractor (if applicable)


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Incident Details

1. Description of the Incident


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2. Describe what happened?


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3. What immediate actions were taken at the time?


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


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




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6. Additional comments / observations


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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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