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Near Miss Investigation Form

Root-cause investigation and corrective action form for workplace near miss events

Company
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Details

Event reference

Event date

Location

Investigation lead

Investigation date

Status

#	Investigation Item	Detail	Completed	Notes
Event Summary
1	Date and time of near miss
2	Location and area
3	Task being performed
4	People involved
5	Description of the event
6	Potential consequences if not avoided
Investigation Details
7	Investigation team members and roles
8	Timeline of events leading to near miss
9	Immediate cause identified
10	5 Whys analysis completed
11	Root cause identified
12	Bow-tie or barrier analysis (if applicable)
Contributing Factors
13	Procedural factors
14	Training or competency factors
15	Equipment or maintenance factors
16	Environmental or site conditions
17	Supervision or communication factors
18	Organisational or systemic factors
Risk Assessment
19	Potential severity (if event had resulted in harm)
20	Likelihood of recurrence
21	Risk rating (likelihood x consequence)
22	Existing controls that prevented harm
23	Additional controls required
Corrective Actions and Close-Out
24	Corrective action 1 description and responsible person
25	Corrective action 2 description and responsible person
26	Corrective action 3 description and responsible person
27	Due dates assigned for all actions
28	Notifiable to WHS regulator (yes / no)
29	Actions verified complete
30	Investigation sign-off and date

Declaration & Sign-Off

I confirm that all items have been inspected/completed as indicated above. Any defects or concerns have been noted and reported.

Completed By

Printed name

Signature

Date

Reviewed / Approved By

Printed name

Signature

Date