Near Miss Report Form
FREE Download
Format: PDF
Editable: No
Pages: 1

This near miss report form template can be used to gather near miss information so that the incident may be investigated, and action taken to minimise the risk being repeated.


A near miss is an undesired event that, under slightly different circumstances, could have resulted in harm to people or damage to property, materials or the environment.

Good health and safety management requires monitoring of your health and safety performance. Reporting of near misses can reduce accidents and improve safety.

Research has shown that for every 90 near misses an accident will occur. The ultimate goal of near miss reporting is to address the incident, and take action to prevent reoccurrence and remove the potential of an accident.

The completed near miss report form can be used to analyse the number an type of near misses occurring, to carry out an information investigation and identify areas of weakness and improvements needed. It can also be used as a record to show that your business takes health and safety seriously.

The document is provided in PDF format and can be printed for use within your business. Once downloaded you are free to save, print and use the accident report form template within your business for as long as you need it.


» Near Miss Details
» Near Miss Circumstances
» Description of Events
» Equipment Involved
» Damage Details
» Witness Details
» Reported By