Get the free Near Miss Form

A form designed to report and analyze near-miss incidents to improve safety and prevent future occurrences.

How to fill out near miss form

How to fill out Near Miss Form

1. Start by entering the date and time of the near miss incident.
2. Provide a detailed description of the near miss, including what happened and where.
3. Include the names and positions of any individuals involved or witnessing the event.
4. Identify the location of the incident using specific area names or codes.
5. Specify the potential consequences of the near miss had it resulted in an accident.
6. Describe any immediate actions taken to address the situation or prevent a recurrence.
7. Sign and date the form to validate the report.

Who needs Near Miss Form?

1. Employees who experience or witness a near miss incident.
2. Management for tracking safety performance and improving workplace safety.
3. Safety personnel who require documentation for risk assessment.
4. Regulatory bodies that may require records of near miss incidents for compliance.

People Also Ask about

What are the 5 rules of incident reporting?

What are the five rules of incident report writing? Timeliness: Always report the incident as soon as possible. Accuracy: Make sure all information provided is accurate and detailed. Completeness: Be thorough and provide all important details. Confidentiality: Handle sensitive and personal information carefully.

What is an example of a near miss on a ship?

Navigational errors and near collisions are among the most critical near-miss incidents in the maritime industry. These incidents include scenarios where vessels narrowly avoid collisions with other ships, submerged objects, or even coastal structures.

What is a good example of near miss?

During roof work, a worker nearly steps backwards off the edge but is called out by a coworker just in time. A tool is dropped from a height but doesn't hit anyone. On a construction site, a temporary guardrail is dislodged but noticed and fixed before anyone leans against it and potentially falls.

What qualifies as a near miss?

A near-miss is a potential hazard or incident in which no property was damaged and no personal injury was sustained, but where, given a slight shift in time or position, damage or injury easily could have occurred.

How do you document a near miss?

In general, here is the information you should include in a near-miss report: Date, time, and location of the incident. Department. Incident description. Root cause (behavior, equipment, etc.) Supporting documents (photos, hazard analyses, etc.) Next steps and specific action items.

How should a near miss be reported?

Near miss reporting procedures: Report the near miss incident, no matter how small or who it happens to. Make sure the scene of the incident is secured as fast as possible. Communicate the incident to supervisors and the safety department. Fill out a near miss report with the exact details of the incident.

What is a near miss form?

Near-miss reporting allows you to pinpoint new risks or unsuitable control measures for existing risks without having to wait for your next scheduled risk assessment or a workplace accident to take place.

How to document a near miss?

In general, here is the information you should include in a near-miss report: Date, time, and location of the incident. Department. Incident description. Root cause (behavior, equipment, etc.) Supporting documents (photos, hazard analyses, etc.) Next steps and specific action items.

For pdfFiller’s FAQs

What is Near Miss Form?

A Near Miss Form is a document used to report an incident that could have resulted in an accident or injury but did not. It helps in identifying potential hazards in the workplace.

Who is required to file Near Miss Form?

Any employee who witnesses or experiences a near miss event in the workplace is required to file a Near Miss Form.

How to fill out Near Miss Form?

To fill out a Near Miss Form, provide details such as the date and time of the incident, location, a description of the near miss, any immediate actions taken, and any witnesses present.

What is the purpose of Near Miss Form?

The purpose of the Near Miss Form is to document incidents that could have led to accidents, allowing organizations to analyze risks, prevent future occurrences, and improve safety measures.

What information must be reported on Near Miss Form?

The information that must be reported includes the date and time of the near miss, the location, a detailed description of what happened, contributing factors, and individuals involved or affected.