Near miss report form
A short form any worker can fill in when something nearly went wrong, with a follow-up page so the supervisor fixes the cause and tells the person who reported it.
Make near misses easy to report
A near miss is an event that could have caused injury, illness or damage, but did not. Each one is a free lesson. Keep the form short, keep copies where people work, and accept reports without looking for someone to blame.
The first page is for the person reporting: what happened, what could have happened, what contributed and what was done right away. The second page is for the supervisor: how serious it could have been, corrective actions, and feedback to the reporter. People keep reporting when they see something change.
The Excel version adds a near miss log with drop-down lists, so you can review reports at safety meetings and spot the same hazard turning up again.
This is a general starting point, not legal advice. Your organization decides how near misses are reported and followed up, and the legal requirements that apply where you work still apply.
To use it on a phone, upload the blank PDF to the form converter and review the result before you publish it.
In Strawboss, crews report near misses from a phone with photos, and follow-up connects to investigations and corrective actions. See near miss reporting. You can start a free trial with no credit card.