Near-Miss Report & Learning Loop (Interactive Form)

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

Use this short, non-punitive form to capture near misses quickly. Report the facts, note any immediate actions, and propose an experiment or fix. The learning loop fields help turn reports into site awareness and small experiments so hazards are addressed before they cause injury, downtime, or quality loss.

This form is intentionally simple so people actually use it. If you’re collecting data for a longer investigation, attach the fuller incident report or link to your EHS system.

","SubmitLabel":"Save Near-Miss","SuccessMessage":"Thanks — your near-miss report was saved. A copy has been sent to the assigned owner and will appear in monthly aggregation reports.","DataType":"NearMissReport","SchemaVersion":1,"Fields":[{"Key":"reporter_name","FieldType":"text","Label":"Reporter name (optional)","HelpText":"Enter your name if you are willing to be contacted for clarification. Leave blank for anonymous reports.","Required":false},{"Key":"contact_info","FieldType":"text","Label":"Contact (phone or email, optional)","HelpText":"Provide contact info only if you want follow-up.","Required":false},{"Key":"department","FieldType":"text","Label":"Department / Team","HelpText":"Which team or area was involved? e.g., Assembly, Maintenance, Packing","Required":true},{"Key":"shift","FieldType":"select","Label":"Shift","HelpText":"Which shift did this occur on?","Required":true,"Options":[{"Value":"day","Label":"Day"},{"Value":"swing","Label":"Swing"},{"Value":"night","Label":"Night"},{"Value":"other","Label":"Other"}]},{"Key":"date_time","FieldType":"text","Label":"Date & time (local)","HelpText":"Format suggestion: YYYY-MM-DD HH:MM. If exact time unknown, give best estimate.","Required":true},{"Key":"location","FieldType":"text","Label":"Location (area / machine / line)","HelpText":"Be specific so follow-up can find the location quickly.","Required":true},{"Key":"what_happened","FieldType":"textarea","Label":"What happened? (brief factual description)","HelpText":"Describe what you observed — stick to the facts, not blame. Include sequence if helpful.","Required":true},{"Key":"immediate_action_taken","FieldType":"textarea","Label":"Immediate action taken (if any)","HelpText":"What did you or others do right away to make it safer? e.g., stopped machine, cord secured, hazard marked.","Required":true},{"Key":"hazard_description","FieldType":"textarea","Label":"Underlying hazard (if known)","HelpText":"What hazard allowed the near miss to happen? e.g., missing guard, poor housekeeping, blocked e-stop.","Required":false},{"Key":"near_miss_categories","FieldType":"checkbox","Label":"Near-miss categories (select all that apply)","HelpText":"Helpful for aggregation and trend analysis.","Required":false,"Options":[{"Value":"slip_trip_fall","Label":"Slip/Trip/Fall"},{"Value":"machine_guard","Label":"Machine guard/guarding"},{"Value":"loto","Label":"Lockout/Tagout"},{"Value":"ergonomics","Label":"Ergonomics"},{"Value":"chemical","Label":"Chemical"},{"Value":"fire","Label":"Fire"},{"Value":"electrical","Label":"Electrical"},{"Value":"material_handling","Label":"Material handling"},{"Value":"procedural","Label":"Procedure/Work instruction"},{"Value":"housekeeping","Label":"Housekeeping"},{"Value":"ppe","Label":"PPE"},{"Value":"other","Label":"Other"}]},{"Key":"potential_consequence","FieldType":"select","Label":"Potential consequence if it had led to an incident","HelpText":"Choose the most likely consequence had this become an injury or failure.","Required":true,"Options":[{"Value":"none","Label":"No injury, no damage"},{"Value":"minor_injury","Label":"Minor injury (first aid)"},{"Value":"medical_treatment","Label":"Medical treatment"},{"Value":"lost_time","Label":"Lost-time injury"},{"Value":"equipment_damage","Label":"Equipment damage"},{"Value":"production_loss","Label":"Production loss"},{"Value":"environmental_harm","Label":"Environmental harm"},{"Value":"multiple","Label":"Multiple/Severe"}]},{"Key":"likelihood","FieldType":"scale","Label":"Likelihood this could have caused harm (1–5)","HelpText":"1 = Very unlikely, 5 = Very likely","Required":true,"Min":1,"Max":5},{"Key":"triage_risk_level","FieldType":"select","Label":"Triage risk level","HelpText":"Suggested method: multiply a nominal severity value (1–5) by likelihood. If product >=12 → High/Critical; 6–11 → Medium; <=5 → Low. Use judgement and local EHS thresholds.","Required":true,"Options":[{"Value":"low","Label":"Low — quick awareness or housekeeping"},{"Value":"medium","Label":"Medium — short experiment or engineering work"},{"Value":"high","Label":"High — requires formal corrective action and follow-up"},{"Value":"critical","Label":"Critical — stop work / immediate safety escalation"}]},{"Key":"recommended_priority","FieldType":"radio","Label":"Recommended immediate priority","HelpText":"Pick the most appropriate immediate path for this report.","Required":true,"Options":[{"Value":"quick_win","Label":"Quick win (fix now, no permit)"},{"Value":"short_experiment","Label":"Short experiment (trial change, <30 days)"},{"Value":"engineering_review","Label":"Engineering review needed"},{"Value":"escalate_ehs","Label":"Escalate to EHS / Stop work"}]},{"Key":"proposed_fix_or_experiment","FieldType":"textarea","Label":"Proposed fix, experiment, or awareness action","HelpText":"Describe a short experiment, fix, or communication that could prevent recurrence. For example: add guard, change SOP step, mark floor, toolbox topic.","Required":false},{"Key":"owner","FieldType":"text","Label":"Owner / person responsible for follow-up","HelpText":"Name or role responsible for running the experiment or implementing the fix.","Required":false},{"Key":"target_date","FieldType":"text","Label":"Target completion or check-back date","HelpText":"Format suggestion: YYYY-MM-DD. Use a realistic short horizon for experiments.","Required":false},{"Key":"check_back_notes","FieldType":"textarea","Label":"Check-back / follow-up notes (for owner)","HelpText":"Owner can record results of experiment or follow-up here.","Required":false},{"Key":"communication_required","FieldType":"yesno","Label":"Is communication required after action?","HelpText":"If yes, indicate where this should be shared (supervisors, toolbox talk, safety meeting).","Required":true},{"Key":"communication_audience","FieldType":"checkbox","Label":"Communication audience (select all that apply)","HelpText":"Where should de-identified learning be shared? (Select all that apply)","Required":false,"Options":[{"Value":"shop_floor","Label":"Shop floor / team"},{"Value":"supervisors","Label":"Supervisors / leads"},{"Value":"safety_meeting","Label":"Safety meeting / toolbox"},{"Value":"all_staff","Label":"All staff"},{"Value":"contractors","Label":"Contractors"},{"Value":"other","Label":"Other"}]},{"Key":"consent_to_share","FieldType":"yesno","Label":"May we share de-identified details for learning?","HelpText":"Sharing helps prevent repeat events. Individual reporter identity will be removed unless you agreed to be contacted.","Required":true},{"Key":"followup_completed","FieldType":"yesno","Label":"Follow-up completed? (owner)","HelpText":"Owner marks yes when experiment/action is completed and checked.","Required":false},{"Key":"followup_results","FieldType":"textarea","Label":"Follow-up results (owner)","HelpText":"Summarize what was done and whether it worked. Attach link to evidence/photos if available.","Required":false},{"Key":"monthly_category","FieldType":"select","Label":"Aggregation category (for monthly dashboard)","HelpText":"Helps group items for monthly trend dashboards.","Required":false,"Options":[{"Value":"process","Label":"Process/procedure"},{"Value":"equipment","Label":"Equipment/guarding"},{"Value":"human_factors","Label":"Human factors/training"},{"Value":"housekeeping","Label":"Housekeeping"},{"Value":"ppe","Label":"PPE"},{"Value":"other","Label":"Other"}]}]}