# 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.

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.

Canonical: https://reuily.com/templates/near-miss-report-form
Use this template: https://reuily.com/form/from-template/near-miss-report-form
Collections: Requests & Intake, Construction, Manufacturing, Logistics & Transportation, Operations
Last updated: 2026-10-24

## Questions

- Question 1: What's your name? (Short Text, required)
- Question 2: What's your work email? (Email, required)
- Question 3: When did it happen? (Date, required)
- Question 4: What time did it happen? (Time, optional)
- Question 5: Where did it happen? (Short Text, required)
- Question 6: What kind of near miss was it? (Single Choice, required). Options: Slip, trip or fall; Struck by or caught in; Forklift or vehicle; Falling object; Electrical; Chemical or spill; Something else
- Question 7: What happened? (Long Text, required)
- Question 8: How bad could it have been? (Single Choice, required). Options: Minor injury; Serious injury; Life threatening; Property damage only
- Question 9: What do you think caused it? (Long Text, optional)
- Question 10: Is the hazard still there? (Yes / No, required)
- Question 11: How could we stop it happening again? (Long Text, required)
- Question 12: Upload a photo of the hazard (File, optional)

## 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

## 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.