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.

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

See the sheet All free tools

Free to print, copy and change. It’s a starting point. Add the lines your equipment and your rules need.

Download itPDF Word Excel Este formato en español

Near-miss report form

Date

Time

Location

Reported by (optional)

Job or project

Equipment involved

What happened

The aim is fixing the cause, not blaming a person.

What could have happened

Contributing factors

Check all that apply.

Rushed or behind schedule
Missing or unclear procedure
Equipment problem
Housekeeping
Weather or lighting
Not enough training
Communication gap
Pedestrian and vehicle mix
Guard or barrier missing
Fatigue

Immediate action taken

Suggested fix

Follow-up

Action

Owner

Due date

Done

Reported by (name, signature, date)

Supervisor reviewed (name, signature, date)

A starting point. Adapt it to your equipment, your procedures and the rules that apply to you.Free template from portalbaseai.com

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.

Book a walkthrough See how incident reporting works

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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.

Related and more free tools

Free tool

A near-miss report form anyone on the crew can fill out.

Near-miss report form

Three habits that make it worth filling out.

Report it the same shift

Say what it could have been

Close the loop

Do this on a phone instead of paper.

Get new free tools by email.

Common questions

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