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Run: Construction Near Miss Reporting Form

Capture construction near misses, hazards, and corrective actions in one structured report. Use it to document what happened, who was exposed, and what needs...

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Report Type

What are you reporting? (required)

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.

Yes No N/A

Event Details

Date observed (required)

Time observed

Project / jobsite name (required)

Location on site (required)

Examples: north scaffold, level 3 east corridor, trench near gate B

What happened? (required)

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? (required)

Was immediate medical attention needed?

May safety contact you for follow-up?

Hazard Description

Hazard category (required)

Describe the hazard or unsafe condition (required)

Include what made the condition unsafe and what could have happened.

Was there immediate danger requiring work to stop? (required)

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 (required)

Interim controls in place until permanent fix is completed

Does this require follow-up verification? (required)

Reporter Information

Your name

Your role

Phone number

Email address

Get your results

Enter your email — we'll send you a PDF of your filled-out template. We won't sign you up to anything; you can opt in to the trial from the email if you want.

Email (required)

Your name (optional)

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