Near Miss Date
Near Miss Date
Near Miss Approximate Time
Near Miss Approximate Time
Visibility at the Time of the Event
Your Role in Event
Contributing Factos
If the system change was implemented, how many weeks were there between the time you identified the change until it was implemented?
Describe the lessons learned as a result of the Near Miss Event. (What lessons were learned? What are your suggestions to prevent a similar event? What actions can correct the situation? ) Identifying department indicators that may identify you or your department will not be included in reports. Keep in mind the following topics when preparing your narrative: Chain of events, Communication, Decision Making, Equipment, Incident Command, Role, Sleep Patterns, Situational Awareness, SOP/SOG, Staffing, Task Allocation, Teamwork, Training, Weather.
Years of Experience at Time of Event
Did the Event Occur Immediately Following Other Employment or Additional Shifts?
Number of Staffed Units Operating at the Time of the Event
How many staffed units where scheduled on the road during the time of the event. Disregard how many units were active or engaged on calls.

Name *
Name