2. Hagerstown Fire Department Firefighter Near-Miss Report
4. 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.
6. 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.
8. 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.
12. Section 1: Reporter Information
14. Today's Date and Time
    Today's Date and Time

    Today's Date and Time
16. Shift/Company
    -- Select One --ABCAdministrationEngine 1Engine 2Engine 3Engine 4Engine 5Truck 1Truck 4
17. Job or Rank
    -- Select One --ChiefBattalion ChiefCaptainFire Apparatus OperatorFirefighterOther
19. Fire Service Experience in years:
    -- Select One --0-34-67-1011-1314-1617-2021-2324-2627-3030+
20. Age
24. Section 2: Event Information
26. Event Date and Time
    Event Date and Time

    Event Date and Time
27. How many hours into the shift were you when the event occured?
    -- Select One --0-45-89-1213-1617-2021-24Volunteer
29. Event Type
    -- Select One --Fire emergency event: structure fire, vehicle fire, wildland fire, etc.Non-fire emergency event: auto extrication, technical rescue, emergency medical call, service call, etc.On-duty activities: apparatus and station maintenance, meetings, tours, etc.Training activities: formal training classes, in-station drills, multi-company drills, etc.Vehicle event: responding to, returning frm, routine driving, etc.Other
30. (if other is selected, please explain briefly)
32. Contributing Factors (select no more than 5)

    1. Accountability
    2. Command
    3. Communication
    4. Decision Making
    5. Equipment
    6. Fatigue
    7. Horseplay
    8. Human Error
    9. Individual Action
    10. Protocol
    11. Situational Awareness
    12. SOG
    13. Staffing
    14. Task Allocation
    15. Teamwork
    16. Training Issue
    17. Unknown
    18. Weather
    19. Other
33. (if other is selected, please explain briefly)
34. Weather at time of Event
    -- Select One --Clear and dryClear with wet surfacesClear with frozen surfacesCloudy and dryCloudy and rainCloudy and snowCloudy and sleetCloudy and freezing rainFog with reduced visibilityFog with poor visibilityNot reported
36. Loss Potential
    -- Select One --EnvironmentalLife threatening injuryLost time injuryMinor injuryProperty damageUnknown
37. What was your event participation?
    -- Select One --InvolvedWitnessed event but not directly involved in the eventTold of event, but neither involved nor witnessed event
39. Do you think this event will happen again?
    -- Select One --YesNoUncertain
43. 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.
45. Narrative
49. 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.
51. Narrative
55. 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).
57. First Name
58. Last Name
59. Telephone Number
60. Email Address
62. Have you submitted this report nationally?
    -- Select One --YesNo
Leave This Blank:


64. 1. Receive an email copy of this form.
65. Email address

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66. Submit

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