Near Miss Form

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Safety is a core value that guides everything we do. Promptly reporting incidents helps us protect each other, improve our workplace, and uphold our commitment to a safe and supportive environment for all.

WHEN TO USE THIS FORM: This form is designed to document near miss incidents – situations that could have resulted in injury, property damage, or equipment loss but did not. Reporting near misses to the safety team helps us identify and fix potential hazards before they cause harm.

E.g., shop, bay, yard, road, etc.
Explain the sequence of events leading to the near miss. Include what was being done, equipment involved, and environmental conditions.
Check all that apply
Check all that apply
Describe what was done immediately and what should be done to prevent reoccurrence.
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