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Near Miss Report Form

Report any event that could have resulted in injury, illness or damage: complete as soon as possible

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PAGE 1 OF 2

Reporter Details

Reporter name

Role / position

Date of near miss

Time of near miss

Location / site

Report date

Near Miss Description: What Happened

What Could Have Happened: Potential Consequences

Potential Severity

First aid Medical treatment Lost time Fatality

Hazard Category

Fall from height Struck by object Electrical Chemical / hazardous substance Manual handling Slip / trip Moving plant / vehicle Confined space Other: _______________

Risk Level Assessment

Likelihood of recurrence

Almost certain Likely Possible Unlikely Rare

Overall risk level (severity × likelihood)

Critical High Medium Low

Near Miss Report - Page 2 of 2

Date

Reporter

Immediate Actions Taken

Recommended Controls (actions to prevent recurrence)

#	Recommended control / action	Responsible person	Due date	Status
1
2
3
4

Photos / Sketches

Attach photos or draw a sketch of the near miss location and hazard. If using paper, staple photos to this form.

Declaration

I declare that I have reported this near miss accurately and to the best of my knowledge. I understand that near miss reporting helps prevent future incidents and that no blame is attributed to the reporter. All recommended controls have been communicated to the relevant supervisor.

Reporter Sign-off

Signature

Print name

Date & time

Supervisor Review & Sign-off

Signature

Print name

Date