Near Miss Report Form Template
A free near miss report form for plants, warehouses and job sites. Workers report a close call from their phone so hazards are fixed before anyone is hurt.
Customize the pages and design to fit your needs.
About this template
Workers say what happened, where, how bad it could have been and how to stop it happening again, with a photo of the hazard. Safety managers see every close call and whether the hazard is still there.
Common uses
- Warehouses and distribution centers
- Plants and production floors
- Construction sites
Key features
- Potential severity
- Hazard photo
- Ideas for a fix from the floor
What this template asks
What's your name?
Short Text
What's your work email?
Email
When did it happen?
Date
What time did it happen?
Time · Optional
Where did it happen?
Short Text
What kind of near miss was it?
Single Choice · Slip, trip or fall, Struck by or caught in, Forklift or vehicle, Falling object, Electrical, Chemical or spill, Something else
What happened?
Long Text
How bad could it have been?
Single Choice · Minor injury, Serious injury, Life threatening, Property damage only
What do you think caused it?
Long Text · Optional
Is the hazard still there?
Yes / No
How could we stop it happening again?
Long Text
Upload a photo of the hazard
File · Optional
How to use this template
Copy it
Select Use template and a copy opens in your workspace as an unpublished draft.
Make it yours
Edit any question or answer, choose a theme, and add your logo.
Share it
Publish, then send the link, show a QR code, or embed the form on your site. Responses arrive in Submissions.
Frequently asked questions
What is a near miss?
An event that could have hurt someone or damaged property but didn't, like a pallet falling where someone was just standing.
How is this different from an incident report?
An incident report records an injury or damage that happened. A near miss report focuses on the hazard, how bad it could have been, and how to fix it.
How do I get workers to report near misses?
Post a QR code in break rooms and on the floor, keep the form to two minutes, and share what was fixed so people see reports lead to change.