Near-Miss Investigation Form & Learning Loop

{ "Title": "Near‑Miss Report & Learning Loop", "IntroductionHtml": "

Purpose: Capture near misses quickly in a non‑punitive way so hazards are analyzed and addressed before they cause injury, downtime, or quality loss. This form is for learning — not punishment. If the situation is an emergency, stop and follow your workplace emergency procedures first.

How to use: Fill the minimum fields needed to explain the event. If you prefer not to be contacted, you may submit anonymously. High‑severity reports will trigger faster review and follow‑up.

", "SubmitLabel": "Submit Near‑Miss", "SuccessMessage": "Thank you. Your near‑miss has been recorded. A safety owner will review the report and follow up as needed. If you asked to be contacted, you may receive a follow up from the assigned owner.", "DataType": "NearMissReport", "SchemaVersion": "1.0", "Fields": [ { "Key": "submit_anonymously", "FieldType": "yesno", "Label": "Submit anonymously", "HelpText": "Check to omit your name from the stored report. Note: anonymous reports may limit our ability to follow up with questions.", "Required": false }, { "Key": "reporter_name", "FieldType": "text", "Label": "Your name", "HelpText": "Optional unless you want to be contacted about follow up.", "Required": false }, { "Key": "date_time", "FieldType": "text", "Label": "Date & time of near miss", "HelpText": "Use format YYYY-MM-DD HH:MM (local time). If unsure, enter approximate time.", "Required": true }, { "Key": "location", "FieldType": "text", "Label": "Location (area, machine, line)", "HelpText": "Be specific so reviewers can investigate quickly.", "Required": true }, { "Key": "department", "FieldType": "text", "Label": "Department / Team", "Required": false }, { "Key": "what_happened", "FieldType": "textarea", "Label": "Brief description: what happened?", "HelpText": "Describe the sequence of events in plain language. Include conditions, actions, and any equipment involved.", "Required": true }, { "Key": "immediate_containment", "FieldType": "textarea", "Label": "Immediate containment actions taken", "HelpText": "What was done right away to stop harm or limit risk (e.g., stopped machine, isolated area, provided first aid, removed material)?", "Required": true }, { "Key": "injury_or_damage", "FieldType": "yesno", "Label": "Was anyone injured or was there property/damage?", "Required": true }, { "Key": "potential_severity", "FieldType": "scale", "Label": "Potential severity if event had caused harm", "HelpText": "1 = Minor (first aid), 3 = Lost time/recordable, 5 = Major/severe", "Required": true, "ScaleMin": 1, "ScaleMax": 5, "ScaleLabels": { "1": "Minor", "3": "Moderate", "5": "Major" } }, { "Key": "root_cause_categories", "FieldType": "checkbox", "Label": "Root cause categories (select all that apply)", "HelpText": "Choose all that seem relevant; you can add detail below.", "Options": [ { "Value": "human_factors", "Label": "Human factor / procedure not followed" }, { "Value": "training", "Label": "Training or competency" }, { "Value": "equipment_failure", "Label": "Equipment / tooling failure" }, { "Value": "maintenance", "Label": "Maintenance issue" }, { "Value": "material", "Label": "Material quality / specification" }, { "Value": "procedure_missing", "Label": "Procedure missing or unclear" }, { "Value": "design", "Label": "Product or process design" }, { "Value": "environment", "Label": "Environmental / housekeeping" }, { "Value": "communication", "Label": "Communication or handover" }, { "Value": "other", "Label": "Other" } ], "Required": true }, { "Key": "underlying_cause_explanation", "FieldType": "textarea", "Label": "Explain the underlying cause(s)", "HelpText": "Use this space to describe why the event happened (not just what). Consider how systems, tools, training, or environment contributed.", "Required": true }, { "Key": "quick_fix_action", "FieldType": "textarea", "Label": "Quick fix or temporary action implemented", "HelpText": "Any immediate fixes to make the situation safe until a permanent solution is implemented.", "Required": false }, { "Key": "recommended_preventive_actions", "FieldType": "textarea", "Label": "Recommended corrective / preventive actions", "HelpText": "Suggest one or more actions that would prevent recurrence (training, engineering change, SOP update, maintenance, signage, etc.). Be specific where possible.", "Required": true }, { "Key": "suggested_owner", "FieldType": "text", "Label": "Suggested owner for follow up (name or role)", "HelpText": "If you don't know, suggest a role (e.g., Maintenance Lead, Shift Supervisor).", "Required": false }, { "Key": "priority", "FieldType": "select", "Label": "Recommended priority for follow up", "Options": [ { "Value": "high", "Label": "High (address immediately)" }, { "Value": "medium", "Label": "Medium (address within days/weeks)" }, { "Value": "low", "Label": "Low (monitor or include in next review)" } ], "Required": true }, { "Key": "target_verification_date", "FieldType": "text", "Label": "Target date to verify preventive action completed", "HelpText": "Optional. Use YYYY-MM-DD or a relative target (e.g., end of month).", "Required": false }, { "Key": "review_cadence", "FieldType": "select", "Label": "Suggested review cadence for this action", "Options": [ { "Value": "immediate_on_shift_huddle", "Label": "Discuss at next shift huddle" }, { "Value": "weekly_safety_huddle", "Label": "Review weekly at safety huddle" }, { "Value": "monthly_review", "Label": "Review monthly" }, { "Value": "quarterly_review", "Label": "Review quarterly" }, { "Value": "one_time_verification", "Label": "One‑time verification only" }, { "Value": "other", "Label": "Other" } ], "Required": true }, { "Key": "communicated_across_shifts", "FieldType": "yesno", "Label": "Has this been communicated across shifts/teams yet?", "Required": true }, { "Key": "lessons_learned_summary", "FieldType": "textarea", "Label": "Suggested short 'lessons learned' summary for communication", "HelpText": "One or two sentences that can be shared at huddles or posted on the safety board.", "Required": false }, { "Key": "contact_me", "FieldType": "yesno", "Label": "Would you like to be contacted about this report?", "Required": false }, { "Key": "non_punitive_ack", "FieldType": "yesno", "Label": "I understand this report is intended for learning and improvement and will not be used punitively", "HelpText": "Checking confirms you understand the non‑punitive intent. If you have concerns, contact your safety representative.", "Required": true }, { "Key": "additional_notes", "FieldType": "textarea", "Label": "Additional notes or attachments references (file references, photo IDs)", "HelpText": "If you have photos or document IDs stored elsewhere, list the file name or reference so reviewers can find them.", "Required": false } ] }