Near Miss Report Form PDF Details

What is a near miss report, and why is it important for safety management? This document is used in workplaces to record incidents that could have resulted in an injury, illness, or damage but, fortunately, did not. By documenting and analyzing near miss incidents, companies can identify hazards, thus preventing problems in the future. The near miss accident report form includes fields for:

- Details of the incident with a description of what happened, where, and how it occurred.

- Date and time of the near miss.

- Names and positions of individuals involved or witnesses.

- Potential outcomes had the near miss resulted in an actual accident.

- Immediate actions taken to address the hazard.

- Recommendations for further preventive measures.

Moreover, collecting near-miss data helps analyze trends and patterns that may not be apparent from more sporadic accident reports. This analysis helps develop effective risk reduction strategies.

Also, some industries and regions require the documentation of near misses as part of compliance with workplace safety regulations. Maintaining these records can help ensure legal accuracy and reduce potential liabilities.

QuestionAnswer
Form Name Near Miss Report Form
Form Length 1 pages
Fillable? Yes
Fillable fields 20
Avg. time to fill out 8 min
Other names near miss form pdf, near miss reporting form samples, near miss reporting form, printable near miss reporting form

Form Preview Example

Workforce Safety & Insurance

www.WorkforceSafety.com

________________________________________________________________________________

NEAR MISS REPORT

A near miss is a potential hazard or incident that has not resulted in any personal injury . Unsafe working conditions, unsafe employee work habits, improper use of equipment or use of malfunctioning equipment have the potential to cause work related injuries. It is everyone’s responsibility to report and /or correct these potential accidents/incidents immediately. Please complete this form as a means to report these near-miss situations.

Department/Location ________________________________ Date: _____________________

Time ___________

am

pm

Please check all appropriate conditions:

Unsafe Act

Unsafe Condition

Unsafe equipment

Unsafe use of equipment

Description of incident or potential hazard : ___________________________________________

______________________________________________________________________________

______________________________________________________________________________

Employee Signature ___________________________________ Date _____________________

(optional)

NEAR MISS INVESTIGATION

Description of the near-miss condition: ______________________________________________

________________________________________________________________________________

Causes ( primary & contributing) ___________________________________________________

________________________________________________________________________________

Corrective action taken (Remove the hazard, replace, repair, or retrain in the proper procedures for the task)

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Signed: _________________________________________ Date Completed ______________

Not completed for the following reason: _______________________________________________

Management ________________________________________ Date _______________________

How to Edit Near Miss Report Form Online for Free

Completing a near miss report is essential for recognizing and reducing workplace hazards before they cause injuries or damages. Here is the guidance on correctly filling out the form.

1. Department and Date

Begin by entering the department or location where the near miss occurred, along with the current date. This helps track and analyze patterns within specific areas of the organization.

2. Time and Conditions

Record when the near miss incident occurred, specifying AM or PM. To describe the primary issue, check all conditions from the options provided, such as unsafe acts, unsafe equipment, unsafe conditions, or unsafe use of equipment.

near miss form conclusion process described (stage 1)

3. Description of Incident

Provide a detailed description of the incident or potential hazard. Include specifics such as what was occurring then, the sequence of events, and any contributing factors.

4. Employee Signature

If comfortable, sign the form to authenticate the report. A date next to the signature is also recommended to document when the report was filed.

5. Investigation Details

In the section for investigation, describe the condition that led to the near miss. Detail any immediate causes and contributing factors to paint a complete picture of the incident.

Management  Date, Signed, and Date Completed of near miss form

6. Corrective Action Taken

Specify any corrective actions that were taken following the near miss. This may include removing or correcting the hazard, repairing equipment, or retraining staff. If no action was taken, note why in the designated area.

7. Sign-off by Management

Finally, the form should be signed by a member of management to acknowledge the report and any actions taken. Include the date the form was completed to close off the documentation process.