Free inspection template
Incident / Near-Miss Investigation Report — Free Template
Run this Incident / Near-Miss Investigation Report from your phone — online or offline — and get a finished PDF report when you're done.
Overview
What is An Incident / Near-Miss Investigation Report?
An Incident / Near-Miss Investigation Report is a structured checklist that helps inspectors systematically verify compliance with the relevant standards or operational requirements. Completing the inspection on mobile produces a timestamped PDF that can be shared immediately with clients or management.
The checklist
Every checkpoint, in full
A read-only preview of the live template. Clone it to run the inspection on mobile, where each item records Pass, Fail or N·A with optional photos and notes.
Usage Disclaimer
0 checksNOTENote on Usage
This report follows OSHA's incident-investigation guidance and captures the data points on OSHA Form 301 (29 CFR 1904). Completing it does not by itself satisfy OSHA recordkeeping or reporting duties, nor does it guarantee a hazard has been eliminated. The employer remains responsible for recording injuries on the OSHA 300/301 forms where required, reporting fatalities and severe injuries to OSHA within the required time limits, and correcting the underlying hazards.
Report Information
4 checksDate of this report
Report prepared by (name and title)
Incident classification
Near-misses had the potential to cause harm but did not. Investigate them with the same rigor — they reveal hazards before someone is hurt.
Potential severity if it happened again
Judge the realistic worst-case outcome, not just what actually happened this time. A near-miss with high potential deserves a full investigation.
Incident Details
7 checksDate of incident
Time of incident
Location where it occurred
Be specific — building, floor, machine, or area.
Department or work area
Task or activity being performed at the time
Equipment, materials, or substances involved
What happened?
Describe the facts in plain language and in order. Stick to what was observed — save analysis of why for the Causal Analysis section.
Person(s) Involved
6 checksWas a person injured, made ill, or exposed?
If No, this is a near-miss or a property/environmental event — the injury detail section will stay hidden.
Name of affected person
Relationship to the company
Job title or role
Time in this job or experience level
New or recently reassigned workers are over-represented in incidents — note if relevant.
Time employee began work that day
Required by OSHA Form 301. Helps evaluate fatigue or shift length as a contributing factor — compare against the time of incident.
Injury / Illness Details
7 checksNature of injury or illness
e.g., laceration, sprain, burn, chemical exposure, fracture.
Body part(s) affected
Object or substance that directly harmed the person
OSHA Form 301 asks for the specific thing that caused the harm — e.g., "chemical splash from sodium hydroxide," "unguarded saw blade," "falling pallet." More specific than the equipment list in Incident Details.
Medical outcome
The most serious outcome that applies. This drives whether the case is OSHA-recordable.
Treatment provided by a licensed healthcare professional?
Estimated days away from work
Best estimate at time of report; update later if needed.
Likely OSHA-recordable?
Generally recordable if it involves medical treatment beyond first aid, restricted duty, days away, loss of consciousness, or a significant diagnosed condition. Confirm against 29 CFR 1904 with your recordkeeper.
Witnesses
3 checksWere there any witnesses?
Witness name(s)
Summary of witness accounts
Interview witnesses promptly and separately. Capture facts, not opinions about fault.
Sequence of Events
2 checksSequence of events leading up to the incident
Reconstruct the chain of events and conditions in the order they happened.
Conditions at the time
Lighting, weather, housekeeping, noise, time pressure, staffing, or anything unusual.
Causal Analysis
5 checksImmediate / direct cause(s)
The unsafe condition or action present at the moment of the incident — e.g., "floor was wet," "guard was removed."
Contributing factors
Other conditions that made the incident more likely or more severe.
Root cause(s)
The underlying system or management factor. Use the "5 Whys": ask why the immediate cause existed, then why that existed, until you reach something the organization controls (missing procedure, no training, no inspection, production pressure).
Primary root-cause category
Has this or a similar incident happened before?
A repeat event means a prior corrective action failed or was never closed out.
Corrective Actions
6 checksImmediate / interim actions already taken
What was done right away to make the area safe — barricade, shutdown, cleanup, first aid.
Corrective action(s) to prevent recurrence
Address the root cause, not just the immediate cause.
Highest level of control in the corrective action
Hierarchy of controls, most to least effective.
Person responsible for corrective actions
A named owner. "The team" does not get it done.
Target completion date
Corrective action status
Evidence
3 checksPhoto of the scene or area
Photograph the scene before it is cleaned up or disturbed, if it is safe to do so.
Photo of equipment, material, or hazard involved
Other evidence collected or reference numbers
e.g., maintenance logs, training records, CCTV reference, workers' comp claim number.
Review & Sign-off
4 checksInvestigator signature
Reviewed by (supervisor or manager name and title)
Management review signature
Date reviewed
Yours to edit
Not quite how your site runs?
Clone it and the checklist becomes yours in seconds. Reword a checkpoint, drop in a whole new section, flag what's critical, and add photo or signature fields wherever proof matters. No code, no form-building.
Field procedure
How to run this inspection
Walk the site area by area. Mark each checkpoint Pass, Fail or N·A as you go, and add a photo on any Fail to document it for the report.
STEP 01
Report Information
Check all items in the Report Information area and record Pass, Fail or N·A for each.
STEP 02
Incident Details
Check all items in the Incident Details area and record Pass, Fail or N·A for each.
STEP 03
Person(s) Involved
OSHA Form 301 (29 CFR 1904) requires a separate report for each injured employee. If multiple people were injured, complete a separate report for each person.
STEP 04
Injury / Illness Details
Check all items in the Injury / Illness Details area and record Pass, Fail or N·A for each.
STEP 05
Witnesses
Check all items in the Witnesses area and record Pass, Fail or N·A for each.
STEP 06
Sequence of Events
Check all items in the Sequence of Events area and record Pass, Fail or N·A for each.
Run your first Incident / Near-Miss Investigation Report today
Clone the template, inspect from your phone, and hand over a finished PDF report before you leave the floor.