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Near-Miss Report

  1. Hagerstown Fire Department Firefighter Near-Miss Report

  2. A near miss event is defined as an opportunity to improve health and safety practices based on a condition or an incident with potential for more serious consequence.

  3. By reporting near misses, other firefighters, EMS providers, and command staff are granted the opportunity to learn from situations experienced by their peers. Those who report near misses through this system play an active role in contributing to the safety of others.

  4. Any information you can provide will be helpful to the extent that you share a “lesson learned” or have a “tip” for others. The system allows you to skip any questions by just jumping ahead to those you are willing or able to answer.

  5. Section 1: Reporter Information

  6. Section 2: Event Information

  7. Contributing Factors (select no more than 5)

  8. Section 3: Event Description

    Describe the event. (Describe the event in the space provided. Your narrative will be reviewed for quality and content. A reviewer will remove all identifying department indicators, names or other information that may identify you. In the next section, you will be asked for suggestions on preventing similar events). Keep in mind the following topics when preparing your narrative: Chain of events, Communication, Decision making, Equipment, Incident Command, Role, Sleep Patterns, Situational Awareness, SOG, Staffing, Task Allocation, Teamwork, Training, Weather. Please provide narrative below.

  9. Section 4: Lessons Learned

    Describe the lessons learned as a result of the incident. (What lessons were learned? What are your suggestions to prevent a similar event? What actions can correct the situation? This will be reviewed for quality and content. A reviewer will remove all identifying department indicators, names or information that may identify you). Keep in mind the following topics when preparing your narrative: Chain of events, Communication, Decision Making, Equipment, Incident Command, Role, Sleep Patterns, Situational Awareness, SOG, Staffing, Task Allocation, Teamwork, Training, Weather.

  10. Contact Information (Optional and Confidential)

    (Providing your contact information is strictly up to you. If you provide your information, it will not be shared with anyone. A reviewer may contact you one time if there are questions regarding your report).

  11. Leave This Blank:

  12. This field is not part of the form submission.