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6 Near Miss Reporting Form Examples You’ll Want to Copy

Looking for near miss reporting form examples to copy?
We've gathered 6 near miss reporting form examples from around the web. Use them to help you create or update your near miss reporting form.
Download the 10-point near miss reporting checklist

1. University of Western Australia

  The University of Western Australia’s “2 Minute Near Miss Report Form” tackles one of the biggest objections around near miss reporting: It’s time consuming.

It also includes a color-coding system, which can be useful in determining an appropriate response and identifying major workplace hazards.

UWA near miss reporting form


2. Selwyn College Cambridge

 Short and sweet, this form asks for only the essentials. While you may find that you need to collect more information, it’s a great reminder that eliminating unnecessary fields can help reduce friction. We also like that the form’s header gives examples of near misses that might be encountered in that environment.

Selwyn near miss reporting form-1

3. Oklahoma State

Oklahoma State’s near miss report for includes room for safety suggestions. It’s a great way to show workers that their input is valued. In addition to giving examples of near misses, the form's header includes some supporting information on why everyone should report near misses immediately. 

OK State near miss form

4. Boy Scouts

Many organizations are shifting their activities online or going totally paperless. The Boy Scouts’ near miss incident report is a fillable PDF so it can be completed on the computer. Like the University of Western Australia’s form, it includes a scoring system to determine the severity of incidents.

 scouts near miss

5. Pallet Service Corporation

Pallet Service Corporation takes the computer-based form a step further with a web form housed on their website. Users can anonymously report near misses and upload an incident picture.

However, this type of stand-alone form doesn’t integrate easily with your other recordkeeping systems. That can make it difficult to report on near misses and analyze the results. 

PSC near miss

6. Perillon

Here's an example of a near miss reporting form in our EHS software system, Perillon. This form enables employees to access a simple web form to record a near miss. No username or password is required and incidents can be submitted anonymously from a cell phone, tablet, or kiosk.

The system uses logic to guide users through the workflow, showing only the fields necessary for that incident type. Workers can add photos, videos, voice recordings, and more.

Then, the system notifies the appropriate administrator so you can kick off an investigation, create corrective actions, and follow the incident through to closure.

Perillon near miss

Your next steps

Streamlining your form and cutting down on the number of questions required is one way to increase the chances that workers will fill it out. Download our free near miss reporting checklist for more ideas.

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Note: This post was originally published December 21, 2017 and was updated April 21, 2021 for freshness and accuracy. 




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