OSHA Near Miss Form

Use the OSHA Near Miss Form to document near-miss incidents, identify the types of near misses and concerns, and apply preventive measures for workplaces.

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OSHA Near Miss Form

OSHA Near Miss Form

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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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OSHA Near Miss Form

Use the OSHA Near Miss Form to document near-miss incidents, identify the types of near misses and concerns, and apply preventive measures for workplaces.

1. What is the name of the department?

2. What is the Building/Work Area?

3. What is the Date and Time of the Incident?

4. Are there any witnesses?

5. What Type of Near Miss is it?

6. What type of concern is it?

7. What is the potential incident/hazard/concern and possible outcome

8. How were the safety procedures violated?

9. Why is an unsafe act committed, or why is the unsafe condition present?

10. Are recommendations/steps taken to prevent a similar incident?