Near Miss Report sample. Edit it or build your own.

Near Miss Report Form

A near miss report form designed for potential hazards or incidents that did not result in any personal injury or property damage. Checkout the Forms Library »

What is a Near Miss Report?

A "near miss" is an unplanned event that had the potential to cause injury or damage but did not. If the event resulted in an incident, injury, or damage then it is not considered a near miss.

If near misses are not identified then workers may acclimate to the hazard until an injury or recordable-incident finally occurs. Near miss reports also provide supervisors with information that allow the hazard to be resolved before it ever becomes an incident.

Near Miss Reporting is one part of a hazard avoidance strategy called Behavior-Based Safety. Behavior-Based Safety (often called BBS) encourages workers to be more "safety aware" by constantly searching for safety hazards (through observation reporting) and by identifying and addressing near misses before they become incidents.

“Holy $#!† that was close!”
- guy who witnessed a near miss

Near-Miss Example

A typical example of a near miss is a ladder falling and nearly striking a worker. No one was hurt, nothing was damaged, and operations were not significantly delayed, but if the person had been just a few inches closer there could have been a serious injury.

How To Implement a Near Miss Program

Here are the keys to developing a fruitful near miss reporting program:

  • Explain - Make it clear what a near miss is
  • Easy - Make it easy to submit reports
  • Praise - Publicly praise quality reports & reporters
  • Respond - Investigate and improve systems based on reports
Near Miss Report - Printable PDF
Download a printable Near Miss Report (PDF).

Sample Near Miss Form

Each KPA EHS account provides a standard Near Miss Report that your team can fill out online or through the free iPhone and Android apps.

If you haven't signed up for KPA EHS yet, here is a paper version of the standard Near Miss Report. Download this PDF and print out a copy for your team members to complete and send-in.

If you do have a KPA EHS account, import the Near Miss Report and then customize the questions. Does your form look totally different? No problem - build your own form in minutes. All forms in KPA EHS support email and app notifications for high-severity responses, plus you can view in-depth reports of all your reporting data.

“At Fortis Energy Services, we implemented KPA EHS at the end of 2018 and are beginning to see clear benefits. Observations and JSA’s are being completed at a 150% increase versus using the paper copy. Training and notices are communicated directly to the employee in an instant.”
- Fortis Energy
Recipient of the 2019 Excellence in Safety Award, North Dakota Petroleum Council

This form is a sample report which can be imported into your KPA EHS account. All forms including this one can be easily modified to fit your organization's policies and procedures.

Don't have a KPA EHS account? Download the printable Near Miss Report PDF form so your team can fill out a paper copy.

Check out the forms library.
Check out the forms library.

Top Features of KPA EHS Reporting

Check out the Forms Overview or learn about specific features:


Form Builder »

Start from a pre-built template or design your own form from scratch.


Offline / Mobile Reporting »

Once team members have downloaded the app, they can fill out reports offline - including attachments! The report will automatically upload once connectivity resumes.


Follow-Up Tracking »

Assign follow-ups within a report and track incomplete items.


Permissions »

You decide who can submit reports, view responses, and more.


Alerts & Notifications »

Setup individual or group notifications for certain reports. For example, you may want notifications for critical issues but not minor ones.


Analysis Tools »

KPA EHS automatically generates rich analytic tools so you can filter, visualize, and export all the data you're collecting.


Participation Reports »

Run participation reports to see who is submitting reports and when they're being submitted.


Electronic Signatures »

Collect electronic signatures when your team fill out reports.


Multilingual »

Forms filled out through the web browser can be automatically translated into 100+ languages.


Revision History

As your team edits a report, the system will automatically track what was changed, the author, and the date.


Data Lists

As projects, locations, etc change, the form will automatically update to include the latest options.


Auto-Hiding Fields

Clicking "Does Not Apply" dozens of times is counter-productive. Instead, hide questions that don't apply.



Some forms can be extremely complex, but that's no problem in KPA EHS. Setup sub-reports to make it easier to fill out in sections.