Near Miss / Good Catch Reporting Form

Near Miss / Good Catch Reporting Form

A near miss is an event where no property was damaged and no injury occurred, but where a slight change in time, position, or circumstances could have led to damage or injury. These are sometimes referred to as close calls, near accidents, or injury-free events. Reporting near misses allows us to identify potential risks and improve safety to prevent future incidents.

A good catch occurs when an employee identifies a potential hazard before it causes any harm or near-miss situation. By taking action early, you help eliminate risks and prevent accidents from happening.

For a safer workplace, we encourage all employees to report both near misses and good catches as soon as possible. Use this form to submit your observations and help us maintain a safe work environment.
Name (Optional):
Date Of Report

MonthDayYear
Date
Near MissGood Catch
Time and Date of the Incident/Hazard:

Hour Minutes

AM/PM Option
MonthDayYear
Location of the Incident/Hazard:
Job number or address
Unsafe ActUnsafe Condition (Jobsite)Unsafe Condition (Equipment)Unsafe Use of EquipmentSafety Policy Violation
Description of the Incident or Hazard:
(Provide a brief summary of what happened or what you observed.)
Site inspection: Why was the unsafe act/condition present?
(Why was the unsafe act/condition present?)
Were any safety procedures not followed? Please describe:
Site inspection: Why was the unsafe act/condition present?
(Describe the conditions, environment, or any contributing factors at the site.)
What could have happened?
(Near Miss: Describe the potential outcome if not prevented.) (Good Catch: Describe the outcome avoided by addressing the hazard.)
YesNo
If Yes Explain:
What actions were taken to address the issue?
(Near Miss: How was it avoided?) (Good Catch: How was the hazard corrected?)
Suggestions for Future Prevention:
(Any suggestions for changes in practices, processes, or safety measures to reduce risk.)
Additional Comments:
(Any other details?)
Near-MissSafety ConcernSafety Idea/Suggestion
(Any suggestions for changes in practices, processes, or safety measures to reduce risk.)
Witnesses (Optional):
Photo (Optional):

Cancelof
Photo (Optional):
Photo (Optional):
Should be Empty: