Construction Near Miss Reporting Form

A workplace form for reporting construction near misses, hazards, root causes, and corrective actions.

Report Type

• What are you reporting?
• Submit anonymously
  Choose this if you do not want to provide your name or contact details. Anonymous submissions help encourage reporting and will be reviewed without identifying you.

Event Details

• Date observed
• Time observed
• Project / jobsite name
• Location on site
  Examples: north scaffold, level 3 east corridor, trench near gate B
• What happened?
  Briefly describe the near miss or hazard using facts, not opinions.
• What work was being performed?

People and Exposure

• How many people were exposed?
• Did anyone get injured?
• Was immediate medical attention needed?
• May safety contact you for follow-up?

Hazard Description

• Hazard category
• Describe the hazard or unsafe condition
  Include what made the condition unsafe and what could have happened.
• Was there immediate danger requiring work to stop?
• What immediate controls were applied?

Root Cause Analysis

• Primary contributing factor
• Why did this happen?
  Describe the underlying cause(s), not just the immediate event.
• Has this happened before on this jobsite?

Corrective Actions

• Corrective actions needed
• Interim controls in place until permanent fix is completed
• Does this require follow-up verification?

Reporter Information

• Your name
• Your role
• Phone number
• Email address