EmailMeForm
Near Miss Report Form
If you experience or witness a near miss event, which is defined as an unintentional unsafe occurrence that could result in an injury, illness, or property damage, please complete this form and submit to the District Office or a Battalion Captain.
Date of Event
MM
/
DD
/
YYYY
REPORTER INFORMATION:
Age at time of event:
Please select
18-24
25-33
34-42
43-51
52+
Experience at time of event/years:
Please select
Probationary
0-3
4-6
7-10
10-14
15+
EVENT INFORMATION:
Event Type:
Fire Event
Non-Fire Event
EMS Event
On-Duty Event
Training Event
Vehicle Event
Fire Event
Structure Fire
Vehicle Fire
Wildland Fire
On-Duty Event
Apparatus Maint.
Station Maint.
Meeting
Tour
Non-Fire Event
Auto Extrication
Tech. Rescue
Service Call
Vehicle Event
Responding to
Returning from
Routine Driving
Training Event
Formal Training
In Station Drill
Out of District Training
Event Date/Time:
Date Time
*
MM
/
DD
/
YYYY
Time:
*
How many hours into the shift:
0-4
5-8
9-12
Weather at time of event:
Clear and Dry
Clear with wet surfaces
Clear with frozen surfaces
Cloudy and dry
Raining
Snowing
Freezing Rain
Fog with reduced visibility
Fog with poor visibiltiy
Contributing Factors:
Accountablity
Decision Making
Human Error
Situation Awarness
Training
Command
Equipment
Individual Action
Staffing
Weather
Communications
Fatigue
Procedures/SOP
Teamwork
Unkown
Describe the event:
*
What do we need to do to correct the event:
*
Contact information (Optional):
Name
First
Last
Phone
###
-
###
-
####
Email
*
Would you like to be contacted?
Yes
No
