Free near miss investigation form
Free near miss investigation form (PDF-ready). Covers root-cause analysis, contributing factors, corrective actions and close-out. Download now.
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Updated 26 Oct 2026
Near Miss Investigation Form
Root-cause investigation and corrective action form for workplace near miss events
Event Summary
Investigation Details
Contributing Factors
Risk Assessment
Corrective Actions and Close-Out
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Short answer
A near miss investigation form records the follow-up to a reported near miss: what happened, root causes and contributing factors, corrective actions, owners and close-out. Safety teams start it soon after each report, often within 24 to 48 hours as practice. Some near misses are dangerous incidents under section 37 of the model WHS Act, which section 38 requires to be notified immediately.
Checked against Model WHS Act (Model WHS Bill as at 5 December 2025 (includes the Model WHS Legislation Amendment (Incident Notification) 2025)) on by the MapTrack templates team. How we check templates
Key takeaways
- The MapTrack near miss investigation form contains 30 checks across 5 sections. Sections covered: Event Summary, Investigation Details, Contributing Factors, Risk Assessment, Corrective Actions and Close-Out.
- A near miss can be a dangerous incident under section 37, such as an uncontrolled escape or collapse; notify those to the regulator immediately.
- Keep each notifiable incident record for at least 5 years (section 38(7)) and leave the site undisturbed as section 39 requires.
- Regulation 38 requires review when a control measure does not control the risk; investigate each near miss to check whether existing controls need to change.
- Starting within 24 to 48 hours is good practice, not law; the WHS Act sets no investigation process for near misses.
- Give every corrective action an owner and due date, and check it worked before closing the investigation.
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What is a near miss investigation form?
A near miss investigation form is a structured document used to investigate and analyse a near miss event after the initial report has been captured. MapTrack helps safety teams digitise the full investigation workflow so every near miss is tracked from report through root-cause analysis to corrective action close-out. This form is distinct from a near miss report form which captures the initial observation. The investigation form covers the detailed analysis that follows including investigation methodology contributing factors corrective actions escalation requirements and formal close-out.
Under the Australian WHS Act a person conducting a business or undertaking (PCBU) has a duty to identify hazards and manage risks. Investigating near misses is a critical part of that obligation because a near miss is an unplanned event that could have resulted in injury illness or damage. The WHS Act also requires PCBUs to notify the regulator of notifiable incidents (section 38) and to preserve the incident site (section 39), and the WHS Regulations require control measures to be reviewed and revised when they fail to control a risk, for example after a notifiable incident (regulation 38). This template supports the internal investigation process but is not a substitute for a notifiable incident report to the relevant state or territory WHS regulator. Organisations that consistently investigate near misses build a richer dataset for identifying systemic weaknesses, allowing safety teams to address procedural gaps and environmental factors before they contribute to a recordable injury.
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Benefits of using this near miss investigation form
- Thorough analysis: structured investigation methodology such as 5 Whys and bow-tie analysis ensures root causes are identified rather than surface symptoms
- Legal compliance: documented investigation records demonstrate the PCBU has met their WHS Act duty to identify hazards and manage risks
- Prevention: identifying contributing factors and implementing corrective actions prevents the near miss from recurring as an actual incident
- Accountability: assigning corrective actions with responsible persons and due dates creates clear ownership of follow-up
- Consistency: every near miss investigation follows the same structured process regardless of who leads it
- Audit trail: a signed investigation record provides evidence for regulator enquiries insurer reviews and internal safety audits
Benefits of digitising forms in MapTrack
When you move your reports from paper to MapTrack, you get:
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- File every completed form against the asset, location or person it covers.
- Download any completed form as a PDF, with failed answers listed at the top.
- Fill in forms offline; they upload when the device is back online.
- Build conditional logic (show or hide questions based on answers).
- Take pictures or attach photos. Not possible with a paper-based form.
- Electronic signatures.
- Edit forms later without reprinting.
- Set who can view, fill in or edit forms with user roles.
- Upload a paper form (PDF, Word, Excel or a photo) and MapTrack's AI builds a digital version for you to check.
- Email safety managers when a hazard report is submitted, with an automation you set up.
- Keep every hazard and incident report against the site it came from, with photos.
- Turn a hazard report into a corrective-action work order with its own review step.
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What to include in a near miss investigation form
This near miss investigation form covers 8 key areas:
- Event summary: restate the near miss event including date time location task being performed and people involved
- Investigation team: record the names and roles of everyone participating in the investigation
- Timeline reconstruction: map the sequence of events leading up to the near miss including decisions actions and conditions
- Root-cause analysis: apply a structured method such as 5 Whys or bow-tie analysis to identify underlying causes
- Contributing factors: identify organisational procedural environmental and human factors that contributed to the event
- Risk assessment: assess the potential severity and likelihood had the event resulted in harm using a risk matrix
- Corrective actions: document each corrective action with a description responsible person due date and priority
- Escalation and close-out: record whether the event is notifiable to the regulator and formally close the investigation once all actions are verified complete
How to use this near miss investigation form
- Gather initial information: obtain the original near miss report and collect statements from witnesses and the people directly involved
- Assemble the investigation team: bring together the supervisor safety representative and any subject matter experts relevant to the task or equipment involved
- Reconstruct the timeline: walk through the sequence of events with the people involved and map out what happened from the start of the task through to the near miss event
- Conduct root-cause analysis: use the 5 Whys method or a bow-tie diagram to trace the event back from the immediate cause through contributing factors to the root cause
- Assess contributing factors: consider whether procedures training equipment maintenance supervision communication or environmental conditions contributed to the event
- Develop corrective actions: for each root cause and contributing factor define a specific corrective action assign a responsible person and set a due date
- Close out and verify: once all corrective actions have been implemented verify their effectiveness and formally close the investigation with sign-off from the investigation lead
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Get the free templateEnter your email above to download the full near miss investigation form as a PDF.Back to download formHow often should you complete this report?
A near miss investigation should be conducted every time a near miss is reported. There is no fixed schedule because investigations are event-driven. The investigation should begin as soon as practicable after the initial near miss report is submitted, ideally within 24 to 48 hours while the details are still fresh.
Under the WHS Act the PCBU must ensure that hazards are identified and risks are managed so far as is reasonably practicable. Investigating near misses is a proactive step in that process. Organisations with strong safety cultures typically investigate all reported near misses regardless of perceived severity because patterns in minor events often reveal systemic risks that could lead to serious incidents.
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Frequently asked questions
Applicable regulatory standards
This template is a starting point. Check the current requirements that apply to your equipment, work and location. The template alone does not establish compliance.
| Standard | Edition | Clauses this template relies on | Source |
|---|---|---|---|
| Model Work Health and Safety Act (Model Work Health and Safety Bill)Dangerous incidents, immediate notification, five-year records and site preservation. Model law: check your state's version. | Model WHS Bill as at 5 December 2025 (includes the Model WHS Legislation Amendment (Incident Notification) 2025) |
| Safe Work Australia (drafted by the Parliamentary Counsel's Committee) |
| Model Work Health and Safety RegulationsControl measures must be reviewed when they fail; a near miss often shows a control that did. | Model WHS Regulations as at 5 December 2025 (cited within as the Work Health and Safety Regulations 2011) |
| Safe Work Australia (drafted by the Parliamentary Counsel's Committee) |
| Model Code of Practice: How to manage work health and safety risksCode guidance on reviewing control measures. It has legal effect only where a jurisdiction has approved it. | November 2024 version (first published December 2011; revised 2018) |
| Safe Work Australia |
| WHS notifications: Incidents, extended absences and suicides fact sheetGuidance on what must be notified; it describes the 2025 model changes, which apply only once a jurisdiction adopts them. | December 2025 update | Whole instrument | Safe Work Australia |
Model Work Health and Safety Act (Model Work Health and Safety Bill)
Edition: Model WHS Bill as at 5 December 2025 (includes the Model WHS Legislation Amendment (Incident Notification) 2025)
Dangerous incidents, immediate notification, five-year records and site preservation. Model law: check your state's version.
- s 37: Defines a dangerous incident: one exposing someone to a serious risk from immediate or imminent exposure to listed events, such as uncontrolled escapes, fires, falling objects and collapses.
- s 38: A PCBU must notify the regulator immediately after becoming aware of a notifiable incident, by the fastest possible means, by telephone or in writing.
- s 38(7): A PCBU must keep a record of each notifiable incident for at least 5 years from the day notice of it was given to the regulator.
- s 39: The workplace's manager or controller must, so far as reasonably practicable, leave a notifiable incident site undisturbed until an inspector arrives or directs, subject to listed exceptions such as rescue.
- s 19: Primary duty of care: a PCBU must ensure, so far as is reasonably practicable, the health and safety of workers and others, including safe plant, systems, training and supervision.
Safe Work Australia (drafted by the Parliamentary Counsel's Committee)
Model Work Health and Safety Regulations
Edition: Model WHS Regulations as at 5 December 2025 (cited within as the Work Health and Safety Regulations 2011)
Control measures must be reviewed when they fail; a near miss often shows a control that did.
- reg 38: Control measures must be reviewed and revised as necessary, including when they fail, before changes creating new risks, for new hazards, after consultation, or on a qualifying representative's request.
Safe Work Australia (drafted by the Parliamentary Counsel's Committee)
Model Code of Practice: How to manage work health and safety risks
Edition: November 2024 version (first published December 2011; revised 2018)
Code guidance on reviewing control measures. It has legal effect only where a jurisdiction has approved it.
- Section 5: Step 4: how to review control measures.
WHS notifications: Incidents, extended absences and suicides fact sheet
Edition: December 2025 update
Guidance on what must be notified; it describes the 2025 model changes, which apply only once a jurisdiction adopts them.
Each source was read at its publisher and the page checked on 26 October 2026. The publisher's current text is the authority.
Check the current source
Near miss investigation form preview
The numbers behind this near miss investigation form
The pages below gather the figures behind this kind of check. Each figure on them carries its source and date, so you can quote it in a toolbox talk, a budget case or a board paper without chasing the original report.
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<p style="font-size:12px;font-weight:700;letter-spacing:0.05em;text-transform:uppercase;color:#071D49;margin:0;">Free template</p>
<p style="font-size:18px;font-weight:700;color:#071D49;margin:6px 0 0;">Near miss investigation form</p>
<ul style="margin:12px 0 0;padding-left:18px;color:#374151;font-size:14px;line-height:1.6;">
<li style="margin:4px 0;">Event summary: restate the near miss event including date time location task being performed and people involved</li>
<li style="margin:4px 0;">Investigation team: record the names and roles of everyone participating in the investigation</li>
<li style="margin:4px 0;">Timeline reconstruction: map the sequence of events leading up to the near miss including decisions actions and conditions</li>
<li style="margin:4px 0;">Root-cause analysis: apply a structured method such as 5 Whys or bow-tie analysis to identify underlying causes</li>
<li style="margin:4px 0;">Contributing factors: identify organisational procedural environmental and human factors that contributed to the event</li>
<li style="margin:4px 0;">Risk assessment: assess the potential severity and likelihood had the event resulted in harm using a risk matrix</li>
</ul>
<p style="font-size:13px;color:#6B7280;margin:14px 0 0;padding-top:12px;border-top:1px solid #E5E7EB;">Free <a href="https://www.maptrack.com/templates/near-miss-investigation-form" style="color:#071D49;font-weight:600;text-decoration:none;">Near miss investigation form</a> by MapTrack</p>
</div>Free to reuse, including commercially. This template is published under a Creative Commons Attribution 4.0 licence. Copy it, adapt it, put it on your own site or in your own docs. All we ask is that you credit MapTrack with a link back to this page. The snippet above already includes that credit, so if you use it as-is you’re covered.
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Writing about this topic? You’re welcome to quote this checklist. Here’s the wording to use so your readers can find the original.
The MapTrack near miss investigation form contains 30 checks across 5 sections.
- Short attribution
- MapTrack Near miss investigation form, https://www.maptrack.com/templates/near-miss-investigation-form
- Reference list
- MapTrack. (2026). Near miss investigation form [Checklist template]. Retrieved from https://www.maptrack.com/templates/near-miss-investigation-form
Free to reuse with credit under a Creative Commons Attribution 4.0 licence. If you’d rather link straight to it, the page is https://www.maptrack.com/templates/near-miss-investigation-form.
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