Form

Near-Miss Report & Learning Loop (Interactive Form)

A short, non-punitive interactive near-miss form that captures essential details, triage data, and a repeatable learning loop (owner, experiment/action, check-back, and communication). Submissions are saved for monthly aggregation and follow-up.

Interactive Tool

Near-Miss Report & Learning Loop

Use this short, non-punitive form to capture near misses quickly. Report the facts, note any immediate actions, and propose an experiment or fix. The learning loop fields help turn reports into site awareness and small experiments so hazards are addressed before they cause injury, downtime, or quality loss.

This form is intentionally simple so people actually use it. If you’re collecting data for a longer investigation, attach the fuller incident report or link to your EHS system.

Enter your name if you are willing to be contacted for clarification. Leave blank for anonymous reports.
Provide contact info only if you want follow-up.
Which team or area was involved? e.g., Assembly, Maintenance, Packing
Which shift did this occur on?
Format suggestion: YYYY-MM-DD HH:MM. If exact time unknown, give best estimate.
Be specific so follow-up can find the location quickly.
Describe what you observed — stick to the facts, not blame. Include sequence if helpful.
What did you or others do right away to make it safer? e.g., stopped machine, cord secured, hazard marked.
What hazard allowed the near miss to happen? e.g., missing guard, poor housekeeping, blocked e-stop.
Helpful for aggregation and trend analysis.
Choose the most likely consequence had this become an injury or failure.
1 = Very unlikely, 5 = Very likely
1.0 10.0
Suggested method: multiply a nominal severity value (1–5) by likelihood. If product >=12 → High/Critical; 6–11 → Medium; <=5 → Low. Use judgement and local EHS thresholds.
Pick the most appropriate immediate path for this report.
Describe a short experiment, fix, or communication that could prevent recurrence. For example: add guard, change SOP step, mark floor, toolbox topic.
Name or role responsible for running the experiment or implementing the fix.
Format suggestion: YYYY-MM-DD. Use a realistic short horizon for experiments.
Owner can record results of experiment or follow-up here.
If yes, indicate where this should be shared (supervisors, toolbox talk, safety meeting).
Where should de-identified learning be shared? (Select all that apply)
Sharing helps prevent repeat events. Individual reporter identity will be removed unless you agreed to be contacted.
Owner marks yes when experiment/action is completed and checked.
Summarize what was done and whether it worked. Attach link to evidence/photos if available.
Helps group items for monthly trend dashboards.
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