Near Miss Corrective Action Form
Report a workplace near miss and track corrective actions to improve safety. Please complete all fields below to ensure thorough documentation and follow-up.
Date of Near Miss
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Near Miss
*
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Describe the Near Miss Event
*
Potential Consequences if Not Avoided
Immediate Actions Taken
*
Contributing Factors (select all that apply)
Equipment malfunction
Human error
Environmental condition
Procedural gap
Other
Corrective Actions Proposed or Taken
*
Person Responsible for Corrective Action
*
First Name
Last Name
Follow-up / Verification Notes
Submit Report
Should be Empty: