Near Miss Reporting Form

Work through it per near miss: the date and the location, the type, the what-happened, the potential outcome, the immediate action, and the cause. The potential is the point, because the potential is what sets the priority, and the form that does not name the potential is the one that gets no action. Add the line to the register, and the form and the register are one document. Print it, or export to CSV for your near-miss system, and the trend of the near misses is the trend the management review reads first.

How to use the template

1. Set the event details — the date, the location, the type, the reporter
2. Write the what-happened — the one factual paragraph, the facts not the interpretation
3. Name the potential outcome — the injury or the damage that was the close call
4. Record the immediate action — what stopped it, what was done right away
5. Record the cause, and add the line to the near-miss register
6. Print it, or export to CSV, and review the trend at the management meeting

Worked example

A near miss, 14:20, at the dock: the type the vehicle, the what-happened the forklift reversed and clipped the pallet stack and the pedestrian stepped back, the potential the struck by, serious, the immediate action the area cleared and the forklift parked, the cause the route crossed the forklift line. The line in the register, the trend the vehicle cluster, and the action the barrier at the crossing. The near miss is the free incident, and the form is the document that makes the free incident the action that prevents the real one.

Standard & legal context

The near miss report is the leading indicator for the UK MHSVR 1999 and the HSE practice, and the OSHA incident and near-miss review in the US. The ISO 45001:2018 clause 10.2 investigation of the incidents including the near misses carries the explicit duty, and the clause 9.1 monitoring carries the leading indicator. The near-miss ratio is the metric, and the form is the document that feeds the ratio, and the register is the data the ratio is built from.

Common mistakes

1. Reporting only the injuries — the near miss is the leading data, and the register with only the recordables is the lagging indicator
2. No potential named — the potential is the judgement that sets the priority, and the form without it is the one that gets no action
3. The immediate action without the cause — the mop is the immediate, and the drain is the cause, and the form carries both
4. No register line — the form is the report, and the register is the trend, and the form without the line is the one that changes nothing