Print this page or download the one-page sheet for handwritten notes.
A near miss is a close call in which someone could have been hurt if circumstances had been slightly different. OSHA’s incident investigation guidance encourages reviewing close calls to identify underlying causes and corrective actions. Follow your employer’s reporting and investigation process.
Use this sheet after immediate safety needs have been addressed. Do not enter an unsafe area, recreate an event, or delay required reporting to complete it. The sheet is a note-taking aid, not a substitute for a required incident report.
Site / area: ____________________ Date / time of event: ____________________
Person recording / role: __________________________________________________
What happened
Activity before the event: __________________________________________________
What you directly observed: ______________________________________________
Relevant equipment / conditions: __________________________________________
Information reported by others, clearly identified: ______________________________
Reporting and available records
Person notified / time: ____________________________________________________
Authorized record references, if any: ________________________________________
Keep facts separate from assumptions. Handle names, photographs, and other records according to the employer’s procedures and applicable privacy requirements.
Review and follow-up
Reviewer / responsible person: _____________________________________________
Further questions: _______________________________________________________
Corrective action agreed by responsible person: ________________________________
Owner / target date / follow-up outcome: _____________________________________
The review should consider work arrangements and contributing conditions. Leave unanswered items visible so they can be followed up.