Near-Miss Report Form
Capture the incidents that almost happened – the cheapest safety data there is.
5 questions · 1 page · about 3 minutes to answer · fully editable after you start
Every accident was preceded by near-misses nobody wrote down. This no-blame report captures them while memory is fresh: what almost happened, the conditions behind it, how bad it could plausibly have been, and the reporter's own fix suggestion – the person closest to the risk usually knows the remedy.
Make it anonymous-capable and two minutes long; near-miss reporting volume is a leading safety indicator, and it only climbs where reporting is fast and consequence-free.
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Page 1
What almost happened
Use this form to report something that almost caused harm. Reporting a near miss helps us fix the cause before someone is hurt, so describe what happened as plainly as you can. It takes about 3 minutes.
Q1.Describe what almost happened, and where.*
Q2.If it had gone wrong, the worst plausible outcome was...*
- Minor first aid
- Lost-time injury
- Serious injury
- Fatality or major incident
Q3.What was the biggest contributing factor?
- Rushing / production pressure
- Equipment condition
- Missing or unclear procedure
- Housekeeping / environment
- Training gap
- Other…
Q4.What would prevent it from recurring? (You are closest to it - your fix matters.)*
Q5.When did it happen?*
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