Near Miss Incident Reporting Log Form
Report workplace near-miss incidents quickly and accurately. Please complete all fields to help us improve safety.
Date of Near Miss Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Type of Near Miss
*
Please Select
Slip, Trip, or Fall
Equipment Malfunction
Chemical Exposure
Struck By Object
Electrical Hazard
Ergonomic Issue
Other
Describe What Happened
*
Potential Consequences if Not Avoided
*
Immediate Actions Taken
*
Were there any witnesses?
*
Yes
No
Names of Witnesses (if any)
Name of Person Reporting
*
First Name
Last Name
Department or Team
*
Submit Report
Should be Empty: