Near Miss Reporting Form

Fields marked with an * are required

You may contact us by filling in this form any time you need professional support or have any questions. You can also fill in the form to leave your comments or feedback.

    Select Your State

    Select Your System

    Date of Incident

    Time of Day

    Type of Incident

    To select multiple incident types, hold the CTRL key on your keyboard, then click each incident type.

    Number of crew members at job site (including yourself)

    Number of potential injuries (including yourself)

    Number of hours worked or on-duty since last rest

    Job being performed

    Weather Conditions

    Has tailgate meeting been conducted?



    To select multiple vehicles/equipment, hold the CTRL key on your keyboard, then click each vehicle/equipment type.

    If other, describe:

    Cause of Incident

    Summary of Incident

    Was appropriate safety equipment provided?

    Was it in use at this time?

    Do you have a safety policy/rule pertaining to this job?

    What is or should be the policy/rule?

    What has been done to prevent recurrence of the incident?