Workplace Injury Near-Miss Report

Workplace Injury Near-Miss Report — Form Fields

This hr template includes 9 fields. Report a near-miss incident that did not result in injury but posed a safety risk. Free to customize and use on ZenBuild.

• Reporter Name (text, required)
• Date of Near-Miss (text, required)
• Time of Near-Miss (text, required)
• Location (text, required)
• Describe What Happened (long text, required)
• What Could Have Gone Wrong? (long text, required)
• Immediate Actions Taken (long text, required)
• Root Cause Category (dropdown selection, required) — options: Equipment failure, Human error, Unsafe condition, Procedural gap, Other
• Witnesses (if any) (text, optional)