Free template
Updated
Near miss report form
A near miss is an unplanned event that could have hurt someone or damaged equipment but did not, this time. A near miss report captures it while it is fresh, so the cause can be fixed before the next one does harm. Page 1 of this form is for the person who saw it: what happened, where and when, the type of event, the worst it could have been, who could have been hurt and what was done right away. Page 2 is for the supervisor or safety lead: why it happened, corrective actions by type of control with owners and due dates, and closure, including telling the reporter what was done. The Excel version is a near miss log with a status and days open for each report, overdue actions flagged, and counts by potential severity and type.
Free to use: print it, copy it and edit it for your team. Enter your name and work email once to download.
Fields for date, time, shift, area and reporter, a box for what happened next to a sketch area, tick boxes for the type of event, a circled scale for the worst it could have been, and a section for the immediate action and the supervisor told.What happened and whereType and potential severityImmediate actionWhy it happenedCorrective action by control typeClosure and feedbackNear miss log in Excel
When to use it
When to use a near miss report form
- Every time someone sees something that could have caused an injury or damage, the same shift.
- Where people have no phone or app to report with, or as the backup when the system is down.
- When a near miss program is starting or restarting, so reports come in the same format.
- To track reports to closure and see which hazards keep coming up.
How to fill it in
- 1
Report it the same shift
Write what happened, where and when, while it is fresh. The name is optional.
- 2
Say how bad it could have been
Circle the worst outcome that could credibly have happened, from first aid to a serious injury, and whether it could happen again.
- 3
Record the immediate action
What was done to make the area safe, and which supervisor was told.
- 4
Find the cause
The supervisor or safety lead asks why until they reach a cause they can fix, and talks to the people involved.
- 5
Fix it with the strongest control
Choose actions from the top of the hierarchy of controls first: eliminate, substitute, engineer, then administrative controls, then PPE. Give each an owner and a due date.
- 6
Close it and tell the reporter
Check the actions on the floor, tell the person who reported it what was done, and check other areas with the same hazard.
A filled-in example
Illustrative, not a benchmarkAn example: a near miss reported in a warehouse and written up the same shift.
The example report, from what happened to the fix
- What happened
A reversing forklift passed within a few feet of a picker at an aisle end
- Worst it could have been
4, a serious injury; it could happen again
- Immediate action
Aisle end coned off; pickers briefed at the next break
- Root cause
Racking blocks the view at the aisle end; no marked crossing
- Corrective actions
Convex mirror and marked crossing (engineering); stop-and-sound rule (administrative)
- What happened: a forklift reversing out of an aisle passed within a few feet of an order picker who stepped out from behind a rack.
- Worst it could have been: 4, a serious injury. It could happen again, as the aisle end has no view either way.
- Immediate action: the aisle end was coned off and pickers were briefed at the next break.
- Root cause: racking at the aisle end blocks the view for drivers and pedestrians, and there is no marked crossing.
- Corrective actions: a convex mirror and a marked pedestrian crossing (engineering), and a stop-and-sound rule at aisle ends (administrative), each with an owner and a due date.
The actions were checked on the floor two weeks later, the picker who reported it was told what changed, and the two other aisle ends with the same layout got the same fix.
Common mistakes
Blaming the reporter
If a report leads to blame, the next near miss goes unreported. Thank people for every report.
Stopping at the immediate action
Coning off an area is containment, not a fix. Find the cause and remove it.
Retraining as the only action
Training and signs are weak controls. Look for a way to remove the hazard or engineer it out first.
No feedback
People who never hear back stop reporting. Tell the reporter what was done.
Closing on paper
Check the actions in the area before you close the report.
Download the template
Free to use: print it, copy it and edit it for your team. Enter your name and work email once to download.
Run this template in LeanSuite
In LeanSuite anyone logs a near miss from a station QR code with a photo, anonymously if the form allows it; rules send each report to an owner with a due date, a serious one can become a safety CAPA, and the reporter is told when it is fixed.
See it in a 45-minute demoIn the lean glossary
Guides
FAQ
Near miss report form: common questions
An unplanned event that could have caused an injury, illness or damage but did not. A box that falls next to someone, or a forklift that stops just short of a person, are near misses.
What happened, where and when, what kind of event it was, the worst it could have been and what was done right away, then the root cause, the corrective actions with owners and due dates, and who closed it.
Allow it. Some people will only report without a name, especially at first. A name helps the investigator ask questions and give feedback, so make it optional rather than required.
In an incident someone is hurt or something is damaged. In a near miss nothing happened, this time. Both have causes worth fixing, and a near miss is the chance to fix them first.
An order for choosing safety actions, from the strongest to the weakest: eliminate the hazard, substitute something less hazardous, engineering controls such as guards or barriers, administrative controls such as procedures, signs and training, and PPE. The form asks for the control type so the strongest one is tried first.
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- Cost per unit worksheet (manufacturing cost per good unit)One product's cost per good unit by materials, labor, machine and overhead, the gap to target, and which cost lever is worth most a year.
- Digital manufacturing readiness assessmentScore 24 statements on process, technology and people from 0 to 4, check the balance between them and rank the gaps by what matters in your plant.
- Manufacturing KPI dashboard templateWeekly plant numbers in, 14 KPIs out: OEE and its parts, first pass yield, scrap, on-time delivery, recordable rate, cost and absence, each against a target.
- RCM worksheet (failure mode and task selection)Failure modes classed as hidden, safety, operational or non-operational, then a task chosen for each: condition-based, discard, failure-finding, redesign or run to failure.
- Error-proofing verification log (daily master-sample check)Each poka-yoke device proved every day or week with a known-bad sample, with missed checks counted and the hours and parts at risk worked out when one fails.
- Downtime reason codes template26 starter codes mapped to the six big losses, a log with drop-downs, a Pareto by code and by loss, and a code card for the line.
- Defect catalogue template with boundary samplesEvery defect with a definition, a class and the reason for it, measured accept and reject limits by zone, boundary samples, a defect log with DPU and Pareto, and an inspector agreement check.
- I-MR chart template (individuals and moving range)Up to 100 single readings with moving ranges, limits from a baseline, five run-rule flags, both charts, a second phase and a reaction log.
- Kaizen event preparation checklistEverything that has to be ready before a kaizen event and done after it: 44 items with owners and due dates from 6 weeks before day 1 to 30 days after, five go or no-go gates and a day-by-day agenda.
- Attribute control chart template (p, np, c and u charts)p, np, c and u charts in one workbook: a chart selector, a sample size check, limits for each subgroup, signal flags and four worked examples.
- Critical spare parts list and stocking levelsAssets ranked by consequence, each part classed and given a stocking policy, and min and max worked out from usage and lead time, with the downtime each stock-out would cost.
- Tier 2 meeting agenda and escalation sheetA 15-minute tier 2 agenda in ten timed blocks, fixed roles and rules, escalation triggers with time limits, and a log that ages every escalation and sends the answer back down.
- Mock recall template: traceability exercise worksheetTrace a finished lot back to every input lot and forward to every first customer, reconcile the quantities against a tolerance and time it against your target.
- ISO 9001 internal audit checklist (production area)46 audit questions for the production floor in 11 processes, each with its ISO 9001:2015 clause, what evidence to look for and the sample to take, plus five defined grades, a findings log, a finding report and a summary by clause.
- Plan for every part (PFEP) templateOne row per part: supplier, pack, container, usage, lead time and locations, with ABC classes, market and line kanban counts and a lineside space check.
- Food plant GMP inspection checklist (21 CFR 117 subpart B)55 checks in the order of 21 CFR 117 subpart B, each citing its paragraph and saying what to look at, with a grade, finding, owner and due date; results by section and grade, a walk route and a bakery example.
- Master sanitation schedule with pre-op verificationA master list of cleaning tasks by area and equipment with frequency, chemical, lockout, who and next due date, a weekly on-time count, and the pre-operational verification log with a release step.
- Changeover matrix templateA from-to matrix of changeover minutes with the clean each transition needs (allergen, colour, format), and a weekly planner that totals the order and suggests a shorter one.
- Measurement uncertainty budget templateA GUM uncertainty budget: Type A and B rows, divisors by distribution, sensitivity coefficients, uc, νeff, k from the t-table, U, TUR and a guard band check.
- Maintenance job plan templateOne job planned on one sheet: steps and craft hours, parts checked against stock, tools, lockout and permits, documents, a ready check for the schedule, and technician feedback.
- Video time study filming checklistA pre-shoot checklist and shot log for filming a time study on video: camera, light, people, settings, power and review.
- Reorder point and safety stock sheet (many parts)Safety stock, reorder point, order quantity and an order list for up to 500 parts, worked out from each part's own demand and lead time history.
- Energy use and EnPI trackerMonthly electricity, gas and fuel in one unit, a 12-month regression baseline, expected against actual energy for each month, an EnPI ratio, the running saving and the tests that say whether the model can be trusted.
- FIFO lane sizing sheetThe maximum for a FIFO lane from the stop it must cover, in whole containers, with length, refill and wait checks for up to eight lanes.
- Pugh matrix templateCompare up to 8 concepts with a datum as better, same or worse on up to 12 criteria, flag must-haves, and carry the strongest into a second round.
- Condition monitoring route sheetA route of measuring points with baselines, alert and alarm limits, a check interval from the P-F interval, readings with rising and overdue flags, and an exceptions list worst first.
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A shift handover sheet, a red tag log, a changeover checklist for one machine: if your team uses it on the floor, ask.