> Home > Divisions & Departments > Fire > Training Division > Valleywide Safety Officers Regional Near Miss Reporting

Valleywide Safety Officers Regional Near Miss Reporting

Near Misses are incidents where, given a slight shift in variables, injury, ill-health or damage easily could have occurred, but did not. Understanding Near Miss trends helps us address systems and procedures before an injury or accident occurs. Your submittals are anonymous unless you choose to provide your name. However, please be aware that all information submitted via this form may be subject to release pursuant to public records laws. Do not include confidential informational in your submittal such as the names of EMS patients.

IMPORTANT: This form should only be used to report Near Miss that have already been resolved and any current or on-going safety issue should be reported immediately to the appropriate authorities within your jurisdiction.

Page 1 of 1
Required
Pick date
Required
Required
Required
Required
Required
What was your participation in the event?
Required
Contributing Factors
Required
Loss Potential
Required
Have you been involved in a similar event?
Required
Do you think this will happen again?
Required
Would you like someone from the safety team to follow-up with you?
Required
Would you be willing to present this Near Miss at a training session or in a safety bulletin?
Required