Near miss report

It is free to fill in online, needs no account, and downloads as a Word document or a PDF. See all Operations and quality templates

• Reported by

  For example: Tomasz Nowak

• Role or teamoptional

  For example: Site operative

• Date of report

  For example: 12 October 2027

• Date and time it happened

  For example: 11 October 2027, about 14:20

• Where

  For example: Elm Street Flats, level 2, north scaffold

• What happened

  Facts only: what you saw, not who is to blame.

  For example: A scaffold board slid off the platform and fell about 6 metres. It landed in the loading bay where a driver had been standing a minute before.

• People involved or who saw itoptional

  For example: Tomasz Nowak (saw it), Liam Byrne (driver)

• How bad could it have been?

  For example: Serious injury

• How likely is it to happen again?

  For example: Possible

• Why it happened (causes)

  Look for the cause behind the cause: ask why several times.

  For example: The board was not tied down Tools and boards were left on the platform at the end of the shift No exclusion zone below the scaffold

• What was done straight awayoptional

  For example: Area below the scaffold was closed off. Boards were tied down.

• Actions to stop it happening again

  Who does what, and by when.

  For example: Add toe boards and tie all loose boards: Scaffold contractor, 14 October Set up exclusion zone on every lift: Site supervisor, immediately Repeat the toolbox talk on scaffolds: Martin Kowalski, 15 October

• Reviewed byoptional

  For example: Martin Kowalski, Site Supervisor

1. 1What happened
2. 2How serious
3. 3Causes
4. 4Done straight away
5. 5Actions to stop it happening again
6. 6Review

1. 01

   Fill in

   Type your details in the form. The document fills itself in as you type; click any gap to jump to its field.

2. 02

   Check

   Read it through. Gaps you have not filled stay marked, so nothing goes out half done.

3. 03

   Download

   Save it as a Word document to edit further, or as a PDF to send or print.

What details does this template ask for?

The form asks for 13 details, starting with Reported by, Date of report, Date and time it happened, Where, What happened. 4 more are optional.

Can I download this template as Word or PDF?

Yes. When you have filled in the form, save it as a Word document to keep editing, or as a PDF to send or print. It is free and needs no account.

Is what I type sent anywhere?

No. What you type stays in your browser while you fill in the document. It only goes to nerix if you choose to open the template in the chat.

What should I check before I use this template?

If someone was hurt or property was damaged, it is an incident, not a near miss: use an incident report, and report it to the authority if the law requires it.

Are these operations templates free?

Most are. Fill in and download them for free as Word or PDF, with no account. A few longer documents are premium: free to fill in, paid once to download, and marked with their price.

Do they meet a standard such as ISO 9001?

They are a practical starting point and certify nothing. Standards and safety laws differ by industry and country, so check what applies to you.

Who should approve a procedure?

The person who owns the process and a manager who can authorise it. The procedure template has fields for both, and for the review date.

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