# Near Miss Report Template, Free Source: https://nerix.ai/templates/near-miss-report Report something that nearly caused harm, find the cause and fix it before someone is hurt. Before you send it 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. ## Fill it in and preview You are signed in. Fill it in your workspace and it is kept as a document you can send, share and have signed. [Open in your workspace](https://app.nerix.ai/documents/templates/near-miss-report) ### Near miss report **Reported by:** Tomasz Nowak **Role or team:** Site operative **Date of report:** 12 October 2027 ## What happened **When:** 11 October 2027, about 14:20 **Where:** Elm Street Flats, level 2, north scaffold 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 it:** Tomasz Nowak (saw it), Liam Byrne (driver) ## How serious **What it could have caused:** Serious injury **How likely to happen again:** Possible ## Causes 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 ## Done straight away Area below the scaffold was closed off. Boards were tied down. ## Actions to stop it happening again 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 ## Review **Reviewed by:** Martin Kowalski, Site Supervisor Reporting a near miss is not blame. It helps us make work safer. Thank you for reporting it. Signed (reporter): ______________________ Signed (reviewer): ______________________ Date: ______________ Templates are a careful starting point, not legal advice. Where the law matters, check what applies where you are. Operations and quality ## What this template is for A near miss report form: what almost happened, where and when, who saw it, the cause, how bad it could have been, and the actions to stop it happening. 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](https://nerix.ai/templates/operations-quality) Operations and quality ## What you fill in The form asks for 13 details. The document fills itself in as you type. - ### Reported by For example: Tomasz Nowak - ### Role or team optional 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 it optional 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 away optional 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 by optional For example: Martin Kowalski, Site Supervisor Operations and quality ## What is inside The parts of this document, in order. - 1 What happened - 2 How serious - 3 Causes - 4 Done straight away - 5 Actions to stop it happening again - 6 Review Templates ## How it works - 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. - 02 ### Check Read it through. Gaps you have not filled stay marked, so nothing goes out half done. - 03 ### Download Save it as a Word document to edit further, or as a PDF to send or print. ### Make it yours with AI Open it in the chat and ask for changes: shorter, firmer, another situation, another language. [Adapt it with nerix](https://nerix.ai/try?template=near-miss-report) ### Was this template helpful? Operations and quality ## Questions people ask ### 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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Operations and quality](https://nerix.ai/templates/class-register) [See all Operations and quality templates](https://nerix.ai/templates/operations-quality) Templates ## More kinds of documents Every category has its own page, so you can see all of its templates at once. ## Use it in nerix ### Use it in nerix - [Templates](https://nerix.ai/product/templates) - [Quality records](https://nerix.ai/product/quality-records) - [Checks](https://nerix.ai/product/audits) ### Learn more - [How to Make a Document From a Template](https://nerix.ai/help/make-a-document-from-a-template) - [Operations and quality](https://nerix.ai/templates/operations-quality)