Near-miss report form
Date
Time
Location
Reported by (optional)
Job or project
Equipment involved
A starting point. Adapt it to your equipment, your procedures and the rules that apply to you.Free template from portalbaseai.com
Free template
A near-miss report form anyone on the crew can fill out.
Nobody got hurt this time. Write down what happened and what could have happened so it gets fixed. Print the sheet or save it as a PDF.
Also calledNear miss form, Close call report, Near-miss reporting template, Good catch form
Free to print, copy and change. It’s a starting point. Add the lines your equipment and your rules need.
How to use it
Three habits that make it worth filling out.
Step 1
Report it the same shift
A close call is easy to shrug off by lunch. Write it while it's fresh.
Step 2
Say what it could have been
The second box is the point. It shows how close it was and why the fix matters.
Step 3
Close the loop
Tell the crew what changed. People stop reporting when nothing happens.
Do this on a phone instead of paper.
Report a near miss from a phone in under a minute, with a photo, no signal needed. The fix gets an owner and a due date, and the report is kept for you.
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Common questions
- What is a near miss?
- An event that didn't hurt anyone or damage anything but could have. A tool dropped from a deck with nobody below is a near miss. Someone below is a different report.
- Does a near-miss report have to be signed?
- Not always. Many sites let people leave their name off so they report more. Your company procedure decides. The reporter's name matters less than the fix.
- Why bother with something that didn't hurt anyone?
- Near misses often share causes with injuries. Fixing the cause on a close call costs less than fixing it after someone gets hurt.
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Guide
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Near miss reporting program: how to get crews to report, review fast, close the loop and find patterns without punishing the person who spoke up.
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Near miss reporting
Near miss reporting talk: what counts as a near miss, why a quick report matters, and how a crew turns a close call into a fix before someone gets hurt.
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Near miss
A near miss is an unplanned event that didn't injure anyone or damage anything but could have.
Glossary
Corrective action
A corrective action is a specific fix, with an owner and a due date, that removes a hazard or the cause of an incident.