# Near Miss Report Template > Source: https://netray.co/tools/near-miss-report-template > Publisher: Netray (netray.co), AI and integration engineering for ERP and manufacturing systems. > Section: Free Tools ## Short answer A quick near miss form with potential severity, contributing factors and follow-up actions that workers can fill in a minute. ## Category ehs-workforce ## Region United States ## Audience - Safety manager - Supervisor - Operator ## Tool **Kind:** template **Output:** document **Fields:** #### Company **Key:** company **Type:** text **Default:** Acme Precision Ltd #### Report number **Key:** report_no **Type:** text **Default:** NM-2026-0187 #### Date of near miss **Key:** date **Type:** date **Default:** 2026-10-18 #### Location **Key:** location **Type:** text **Default:** Shipping dock 2 #### Reported by (optional) **Key:** reporter **Type:** text **Default:** Forklift operator #### Category **Key:** category **Type:** select **Options:** - Struck by - Slip, trip or fall - Caught in or between - Electrical - Chemical - Ergonomic - Fire - Vehicle or forklift - Other **Default:** Vehicle or forklift #### Potential severity if it had gone wrong **Key:** potential **Type:** select **Options:** - Minor - Moderate - Serious - Fatal **Default:** Serious #### Likelihood of recurrence **Key:** likelihood **Type:** select **Options:** - Unlikely - Possible - Likely - Almost certain **Default:** Possible #### What happened **Key:** what **Type:** textarea **Default:** A pedestrian stepped out from behind racking into the forklift aisle as a loaded forklift was turning. The driver braked and stopped about one meter away. #### Contributing factors **Key:** factors **Type:** textarea **Default:** Blind corner, no mirror, pedestrian walkway not marked at the end of the aisle, horn not sounded. #### Suggested fix **Key:** suggest **Type:** textarea **Default:** Install convex mirror, mark pedestrian crossing and stop line, add a barrier at the aisle exit. **Blocks:** #### Near Miss Report **Body:** Company: {{company}} Report no.: {{report_no}} Date: {{date}} Location: {{location}} Reported by: {{reporter}} #### Classification **Body:** Category: {{category}} Potential severity: {{potential}} Likelihood of recurrence: {{likelihood}} #### What happened **Body:** {{what}} #### Contributing factors **Body:** {{factors}} #### Suggested fix **Body:** {{suggest}} #### Review and follow-up **Table:** **Columns:** - Action - Owner - Due date - Status **Rows:** #### Feedback to reporter **Body:** Date feedback given: ____________ Outcome communicated: Yes / No #### Review **Signatures:** - Supervisor - Safety representative **Notes:** A starting point, not legal advice. Keep the form short and non-punitive so people use it. Escalate any near miss with high potential severity to a full incident investigation. ## Content **Intro:** A near miss is an event that could have caused harm but did not. Collecting them gives you the same lessons as injuries at no human cost. This template is a one-page form people can complete quickly, with potential severity and a suggested fix so the report leads to action. **Sections:** #### How to use this template **Body:** Make the form easy: the more fields you require, the fewer reports you receive. Fill in the date, place and category, describe what happened in plain words and say what could have happened. Pick the potential severity and the likelihood it will happen again. The contributing factors and suggested fix fields invite the worker to say what they think should change. Export to PDF for a paper box or Word for a shared drive, then log each report in a register and close the loop with feedback to the reporter. #### Why near misses matter **Body:** Safety pyramid models suggest that for each serious injury there are many minor ones and far more near misses, although the exact ratios are debated and vary by industry. The practical point holds: near misses expose the same hazards and system failures that eventually cause injuries. A strong reporting culture is a leading indicator, unlike TRIR, which only records harm after the fact. Rank reports by potential severity, not by actual outcome, so a close call that could have been fatal gets the attention it deserves. **Bullets:** - Track number of reports, time to close and % with feedback - Do not discipline reporters - Review trends monthly by location and category - Escalate high-potential events for full investigation #### Worked example **Body:** In the example a forklift stopped about a meter from a pedestrian at a blind corner. No harm occurred, but the potential severity is serious and the likelihood of recurrence is possible. The contributing factors point to physical layout and not to the driver alone, so the fixes are a mirror, a marked crossing and a barrier. That is the kind of engineering control that prevents the next event without depending on someone remembering to be careful. #### Common mistakes **Body:** Programs fail when reports disappear into a box with no feedback, when reporters are blamed, or when the form is too long. Another mistake is counting reports as a performance target for individuals, which encourages trivial entries. Set a target for response and closure instead, and publish what was fixed. Connect the register to your corrective action process so a recurring near miss in one area triggers a formal review. **Cta:** If you want near miss counts, locations and closure times to appear in the same dashboard as production and maintenance data, we can set that up read-only on your existing systems. **Faq:** #### What counts as a near miss? **Answer:** An unplanned event that did not cause injury, illness or damage but had the potential to. Examples include a dropped load that lands nearby, a slip that is caught, or an electrical arc with no contact. #### Is a near miss recordable by OSHA? **Answer:** No. Recordability depends on an actual work-related injury or illness meeting the criteria in 29 CFR 1904. A near miss has no injury, so it is not recorded on the OSHA 300 log, though you should keep your own record. #### Should near miss reports be anonymous? **Answer:** Offer both. The name is useful for follow-up questions, but allowing anonymous submission increases reporting in cultures where people fear blame. The reporter field in this template is optional. #### How fast should a near miss be reviewed? **Answer:** Triage within a day or two for severity, and close or assign actions within a few weeks. High-potential events deserve a full investigation straight away. ## Search terms near miss report template, near miss reporting form, near miss form word, close call report form, near miss report example, near miss log, unsafe condition report form, hazard observation card --- Talk to an engineer: https://netray.co/contact?intent=erp_ai | Machine catalog: https://netray.co/agent/catalog.json