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Near Miss Report Form
Capture learning before someone is hurt. Describe what happened and which controls failed or were missing, rather than framing the report around individual blame.
How to use this worksheet
- Make the area safe first; stop the work and notify responsible persons if the hazard remains.
- Record the date, place, work activity, event sequence and witnesses objectively.
- Separate the actual outcome from the credible harm that might have occurred.
- Identify technical and organisational contributing factors with the workers involved.
- Assign corrective-action owners and dates, then verify both completion and effectiveness.
Worked field example
Worked example — A hand tool falls onto a walkway without striking anyone. Actual outcome: No injury. Potential outcome: Head injury. Immediate action: Isolate the walkway and stop overhead work. Prevention: Tool tethering, exclusion zone and pre-shift verification.
SERNEM — FIELD WORKSHEET
Near Miss Report Form
Adapt this worksheet to actual site conditions.
Event details
Corrective and preventive actions
| Action | Owner | Due date | Status / effectiveness check |
|---|---|---|---|
Event description
Learning and follow-up
Follow emergency and local/organisational reporting procedures. This form does not replace mandatory incident notification or statutory reporting.
Frequently asked questions
What is a near miss?
An unplanned event that could credibly have caused injury or damage but did not do so in its actual outcome.
Must the reporter be identified?
It depends on company policy and local requirements. Focus on the facts needed to control the risk without collecting unnecessary personal information.
Related SERNEM resources
Technical sources
Follow emergency and local/organisational reporting procedures. This form does not replace mandatory incident notification or statutory reporting.