Near Miss Reporting Checklist
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Incident Details
Basic information about the near miss event.
Date of Near Miss
Time of Near Miss
Specific Area/Workstation
Brief Summary of Event
Estimated Speed (if applicable)
Severity Level (Potential Harm)
Reported By (Role)
Location & Equipment Involved
Details about where the event occurred and what equipment was involved.
Specific Location of Near Miss
Work Area/Department
Type of Equipment Involved
Equipment ID/Number (if applicable)
Detailed Description of Equipment Involved (Condition, Last Inspection)
Equipment Serial Number (if applicable)
People Involved
Information regarding individuals who witnessed or were potentially affected by the near miss.
Number of Employees Potentially Affected
Name of Reporter
Job Title of Reporter
Witness Statements (if any)
Departments Involved
Name(s) of Individuals Directly Involved (if known)
Job Titles of Individuals Directly Involved (if known)
Description of Event
A detailed narrative of what happened leading up to the near miss.
Describe the sequence of events leading up to the near miss. Be as detailed as possible.
What actions were being performed by involved personnel at the time?
Specify the exact location where the near miss occurred (e.g., machine number, work station).
What time did the near miss occur?
If equipment was involved, estimate the speed or operating parameter that contributed (e.g., RPM, pressure, temperature).
Describe any unusual sounds, smells, or visual observations preceding the near miss.
Was there a deviation from standard operating procedures?
Contributing Factors
Identification of the underlying causes and conditions that contributed to the near miss.
Was a procedure/work instruction not followed?
Was training adequate for the task?
Describe any communication breakdowns that may have contributed to the near miss.
Estimated Speed (if applicable, e.g., forklift speed in mph/kph)
Were environmental factors a contributing factor (e.g., lighting, noise, visibility)?
Describe any equipment malfunctions or maintenance issues that may have played a role.
Was there a time pressure or deadline that may have influenced behavior?
Any other factors you believe contributed to the near miss?
Potential Consequences
Assessment of what could have happened if the near miss hadn't been averted.
Describe the potential injury or damage that could have occurred.
Estimated cost of potential damage (if applicable, in USD)
Which of the following potential consequences were considered?
If 'Other' was selected above, please describe the potential consequence.
Severity Rating (Based on potential impact)
Corrective Actions Proposed
Suggestions for actions to prevent similar events in the future.
Detailed Description of Proposed Corrective Action
Estimated Cost of Corrective Action (USD)
Action Priority Level
Target Completion Date
Responsible Department(s)
Corrective Action Type
Rationale for Chosen Action
Reporting & Verification
Details regarding who reported the incident and verification steps.
Reporter Name
Date of Report
Time of Report
Department of Reporter
Report Status
Reviewer Name (if applicable)
Date of Review (if applicable)
Reviewer Comments (if applicable)
Verification Method
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