Near Miss Report Template

1. Report Overview

This section provides a brief overview of the near miss incident, including the date, time, and location.

• Date: [Insert Date]

• Time: [Insert Time]

• Location: [Insert Location]

2. Description of the Incident

Detail the events leading up to the near miss, including any relevant actions taken by personnel.

Example: "On [Insert Date], at approximately [Insert Time], a near miss occurred when [describe the incident]."

3. Contributing Factors

Identify any factors that contributed to the near miss, such as equipment failure, human error, or environmental conditions.

• [Factor 1]

• [Factor 2]

• [Factor 3]

4. Immediate Actions Taken

Document any immediate actions taken in response to the near miss.

Example: "Following the incident, [describe actions taken]."

5. Recommendations for Prevention

Provide recommendations to prevent similar incidents in the future.

• [Recommendation 1]

• [Recommendation 2]

• [Recommendation 3]

6. Follow-Up Actions

Outline any follow-up actions that will be taken to address the near miss.

Example: "A follow-up meeting will be held on [Insert Date] to discuss further actions."