OSHA Near Miss Form
Section 1 of 1 · 10 questionsOSHA Near Miss Form
What is the name of the department?
What is the Building/Work Area?
What is the Date and Time of the Incident?
Are there any witnesses?
What Type of Near Miss is it?
What type of concern is it?
What is the potential incident/hazard/concern and possible outcome
How were the safety procedures violated?
Why is an unsafe act committed, or why is the unsafe condition present?
Are recommendations/steps taken to prevent a similar incident?
Checklist by GoAudits. This checklist is an example: we do not guarantee compliance with the laws applicable to your territory or industry. Seek professional advice to adapt it to your workplace or jurisdiction.
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