Free near miss report form
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Free near miss report form (PDF-ready). Hazard observed, potential consequences, risk level, location details and recommended controls. Download free.
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See the first part of the near miss report form below. Download the full version above.
What is a near miss report form?
A near miss report is a record of an unplanned event that did not cause injury, illness or damage but had the potential to do so. It captures what happened, what could have happened, the hazard category (e.g. fall, struck by, electrical, chemical), potential severity, likelihood of recurrence, and the risk level. Near miss reporting is a leading safety indicator; organisations that actively report and act on near misses experience fewer serious incidents. In Australia, near miss reporting is widely considered best practice under WHS legislation and many principal contractor management systems mandate it.
The report is typically completed by the worker who experienced or witnessed the event, then reviewed by a supervisor who determines whether further investigation or corrective action is required. High-quality near miss data helps safety teams identify recurring hazards, prioritise controls and demonstrate continuous improvement to regulators and clients. This template provides a structured format that guides the reporter through each field, ensuring no critical information is missed.
Under Section 19 of the Work Health and Safety Act 2011, persons conducting a business or undertaking (PCBUs) must ensure, so far as is reasonably practicable, the health and safety of workers. Section 28 places a complementary duty on workers to take reasonable care for their own health and safety and to cooperate with reasonable policies and procedures. Near miss reporting directly supports both obligations by creating a feedback loop between frontline workers and management. Organisations certified to AS/NZS ISO 45001 are expected to maintain processes for reporting hazardous situations, and near miss data feeds directly into the continual improvement cycle required by Clause 10.3 of that standard.
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Benefits of using this near miss report form
- Prevent incidents before they happen: - identifying and controlling hazards revealed by near misses stops them becoming injuries.
- Build a proactive safety culture: when workers see near miss reports lead to action, they are more likely to report hazards.
- Identify trends and patterns: aggregate near miss data reveals recurring hazards across sites, shifts or activities.
- Regulatory compliance: demonstrate due diligence and continuous improvement to regulators and principal contractors.
- Reduce costs: preventing injuries avoids workers' compensation claims, downtime, equipment damage and reputational harm.
- Audit trail: signed near miss reports create a documented record of hazard identification and response that supports WHS audits, insurance reviews and regulator enquiries.
Benefits of digitising forms in MapTrack
When you move your reports from paper to MapTrack, you get:
- Field users can easily scan a QR code to complete a form on mobile. Unlimited users.
- Automatically get alerts when faults are identified.
- Link every form digitally as a PDF to the relevant asset, location or person.
- Receive a digital PDF copy with every submission to your email.
- Ability to share forms digitally.
- 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.
- Restrict permissions (who can view, complete or approve).
- Build forms with AI (describe what you need and MapTrack suggests the form).
- Escalate critical hazards instantly to safety managers via push notification.
- Maintain an auditable safety register that satisfies WHS regulator requests.
- Correlate incident trends across sites with built-in safety analytics.
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What to include in a near miss report form
This near miss report form covers 11 key areas:
- Reporter details: name, role, date and time of the near miss.
- Location/site: specific area where the event occurred.
- Near miss description: what happened and what could have happened.
- Potential severity: first aid, medical treatment, lost time or fatality.
- Likelihood of recurrence: how likely the event is to happen again.
- Risk level matrix: severity x likelihood to determine risk rating.
- Hazard category: fall, struck by, electrical, chemical, manual handling, etc.
- Immediate actions taken: what was done to control the hazard on the spot.
- Recommended controls: additional controls to prevent recurrence.
- Photos/sketches area: space for visual evidence or diagrams.
- Supervisor review and sign-off: supervisor acknowledgement with date.
How to use this near miss report form
- Complete reporter details. Your name, role, date and time of the near miss.: Record your full name, job title and the exact date and time the near miss occurred or was first observed. If you witnessed the event but were not directly involved, note that distinction. Accurate time stamps are essential because they allow investigators to cross-reference shift rosters, CCTV footage and other records. If the event happened earlier in the shift but you are reporting it later, record both the event time and the reporting time so there is no ambiguity.
- Record the location or site area where the event occurred.: Be as specific as possible. Rather than writing "warehouse", record "warehouse aisle B3, near the forklift charging bay on the west wall". Include the site name, building or zone, floor level and any nearby landmarks or equipment. Precise location details help investigators reproduce the conditions and identify whether the hazard is site-specific or systemic across multiple areas. If your site uses grid references or GPS coordinates, include those as well.
- Describe what happened and what could have happened if the situation had been slightly different.: Write a clear, factual account of the sequence of events. Start from the task being performed, describe the conditions at the time, and explain what went wrong or what was observed. Then describe the potential outcome, for example "a 5 kg fitting fell from the scaffold to the walkway below; if a worker had been standing in the drop zone it could have caused a serious head injury." Separating what happened from what could have happened helps investigators assess the true risk level.
- Assess the potential severity (first aid, medical, lost time, fatality) and the likelihood of recurrence to determine the risk level.: Use your organisation's risk matrix to rate severity and likelihood. Severity categories typically range from first aid (minor cuts, bruises) through medical treatment injury, lost time injury, permanent disability to fatality. Likelihood ranges from rare through unlikely, possible, likely to almost certain. Multiply or cross-reference the two ratings to produce an overall risk level (low, medium, high or critical). Be honest in your assessment; underrating severity undermines the value of the reporting system and may result in inadequate corrective actions.
- Select the hazard category (fall, struck by, electrical, chemical, etc.).: Classify the hazard using standard categories such as fall from height, struck by object, caught between, electrical contact, chemical exposure, manual handling strain, slip or trip, vehicle or mobile plant interaction, fire or explosion, or environmental release. Selecting the correct category enables trend analysis across the organisation. If the event involves multiple hazard types, select the primary category and note secondary hazards in the description field.
- Record any immediate actions you took to control the hazard.: Document every action taken on the spot to make the area safe. Examples include barricading the drop zone, isolating defective equipment, cleaning up a spill, repositioning a load, or warning nearby workers. If you escalated the issue verbally to a supervisor, record their name and the time you notified them. Immediate actions are temporary controls; they reduce risk in the short term but do not replace the formal corrective actions that should follow from the investigation.
- List recommended controls to prevent recurrence.: Suggest practical measures that address the root cause, not just the symptoms. Follow the hierarchy of controls: elimination first, then substitution, engineering controls, administrative controls and PPE as a last resort. For example, if a fitting fell because a tool tether was not used, recommend mandatory tool tethering for all overhead work rather than simply reminding workers to be careful. Each recommendation should be specific enough for a supervisor to action it directly.
- Attach photos or sketches if available. Sign and date the form and submit to your supervisor for review.: Photographs taken at the time of the event are some of the most valuable evidence in a near miss investigation. Capture the hazard, the surrounding area, any equipment involved and any temporary controls you put in place. If a camera is not available, draw a simple sketch showing the layout, the position of people and equipment, and the path of the hazard. Sign and date the completed form, then submit it to your direct supervisor within the same shift or within 24 hours at the latest.
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Back to download formHow often should you complete this report?
A near miss should be reported as soon as it occurs or is observed - ideally before the end of the shift. The sooner a near miss is reported, the sooner the hazard can be controlled and the more accurate the details will be. There is no "too minor" threshold - if an event had the potential to cause harm, it should be reported. Encourage all workers, contractors and visitors to report near misses without fear of blame. A strong near miss reporting culture is one of the best predictors of overall safety performance.
WHS Act 2011, Section 38, defines 'dangerous incidents' as a subset of near misses that must be notified to the regulator. Organisations with a strong reporting culture often set a target response time for near-miss reports, such as 24 hours for submission and 5 days for investigation close-out.
Frequently asked questions
Applicable regulatory standards
This template aligns with the following regulations and standards:
- Work Health and Safety Act 2011 (Cth) - Section 19 (primary duty of care)
- Work Health and Safety Act 2011 (Cth) - Section 28 (duties of workers)
- WHS Regulations 2011 - Part 3.1 (incident notification)
- AS/NZS ISO 45001:2018 - Occupational health and safety management systems
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