Near Miss Reporting Form

Form for reporting near miss incidents, including location, description, root cause, corrective actions, and lessons learned.

Incident Summary

• Date of Near Miss
  Select the date the near miss occurred.
• Time of Near Miss
  Approximate time the event occurred.
• Location
  Enter the specific area, site, or workstation where the near miss occurred.
• Near Miss Type
  Choose the category that best matches the event.
• Brief Summary
  Describe what happened in 2-5 sentences, focusing on observable facts.

Detailed Description

• What Happened?
  Describe the sequence of events leading up to the near miss.
• What Could Have Happened?
  Explain the potential injury, damage, or loss that was narrowly avoided.
• Immediate Action Taken
  Document any immediate containment or stop-work actions taken after the event.
• Were There Witnesses?
  Select whether anyone else observed the event.

Root Cause and Contributing Factors

• Root Cause
  State the most likely underlying cause, using facts rather than blame.
• Contributing Factors
  Select all factors that may have contributed to the event.
• Unsafe Condition Observed
  Describe any unsafe condition, hazard, or control failure that was present.

Corrective Actions

• Corrective Actions
  Add one or more actions that will reduce the chance of recurrence.
• Priority
  Set the urgency based on risk of recurrence.
• Follow-Up Required?
  Choose whether the event needs additional review or verification.
• Follow-Up Details
  Describe the review, verification, or investigation needed.

Lessons Learned

• Lessons Learned
  Summarize the key takeaway that should be communicated to others.
• Share with Team?
  Indicate whether this report should be shared in a safety meeting or toolbox talk.
• Preferred Communication Channel
  Choose how the lesson should be communicated.