Workplace Near-Miss Report Form

Workplace Near-Miss Report Form — Form Fields

This operations template includes 10 fields. Report near-miss incidents in the workplace to support proactive safety improvements and root cause analysis. Free to customize and use on ZenBuild.

• Reporter Name (text, required)
• Reporter Email (email, required)
• Date and Time of Near-Miss (text, required)
• Location in Facility (text, required)
• Type of Near-Miss (dropdown selection, required) — options: Slip/Trip/Fall, Struck by Object, Caught In/Between, Electrical, Chemical Exposure, Vehicle/Equipment, Other
• Description of What Happened (long text, required)
• What Could Have Been Injured or Damaged? (long text, required)
• Immediate Actions Taken (long text, required)
• Was Equipment or a Process Involved? (multiple choice, required) — options: Yes, No
• Recommendations to Prevent Recurrence (long text, optional)