Near-Miss Investigation & Learning Form

{"Title":"Near-Miss Investigation & Learning Form","IntroductionHtml":"

Welcome — thank you for reporting. This quick, non‑punitive form helps teams capture what happened, what was done immediately, and what to do next so hazards can be removed and lessons can be shared at the next safety huddle. Aim for clarity and speed: concrete facts, immediate actions, and one short learning summary you can read aloud.

This form is for immediate learning and follow-up. It does not replace formal EHS audits, legal reporting, or organization‑specific regulatory procedures.

","SubmitLabel":"Save Near‑Miss Report","SuccessMessage":"Thank you — your near‑miss report has been saved. The assigned safety lead will review the report and confirm follow‑up actions. Share the learning summary at your next huddle.","DataType":"NearMissReport.v1","SchemaVersion":"1.0","Fields":[{"Key":"reporter_name","FieldType":"text","Label":"Your name (optional)","HelpText":"Leave blank to report anonymously. Providing a name can help with clarifying details if needed.","Required":false},{"Key":"submitter_role","FieldType":"select","Label":"Role","HelpText":"Choose the role that best describes you.","Required":false,"Options":[{"Value":"operator","Label":"Operator / Machine operator"},{"Value":"supervisor","Label":"Supervisor / Team lead"},{"Value":"maintenance","Label":"Maintenance / Technician"},{"Value":"quality","Label":"Quality"},{"Value":"other","Label":"Other"}]},{"Key":"date_time","FieldType":"text","Label":"Date & time of near miss","HelpText":"Enter local date and time (e.g., 2026-09-15 14:35). If unknown, estimate.","Required":true},{"Key":"location","FieldType":"text","Label":"Location (work area / machine / line)","HelpText":"Be specific so the area can be inspected quickly.","Required":true},{"Key":"brief_description","FieldType":"textarea","Label":"Brief description of what happened","HelpText":"What exactly occurred? Who or what was involved? Keep to the facts.","Required":true},{"Key":"immediate_action_taken","FieldType":"textarea","Label":"Immediate action taken","HelpText":"What was done right away to control the hazard or stop the event? (e.g., isolated power, stopped machine, removed person from area)","Required":true},{"Key":"immediate_hazards_controlled","FieldType":"yesno","Label":"Was the immediate hazard controlled?","HelpText":"Select yes if the hazard is currently controlled or removed; select no if it remains.","Required":true},{"Key":"potential_consequences","FieldType":"textarea","Label":"Potential consequences if unaddressed","HelpText":"What could have happened? Consider injury, quality loss, equipment damage, downtime.","Required":true},{"Key":"potential_severity","FieldType":"scale","Label":"Potential severity (estimate)","HelpText":"1 = Minor / low impact, 5 = Major / high impact","Required":true,"ScaleMin":1,"ScaleMax":5},{"Key":"root_cause_prompts","FieldType":"checkbox","Label":"Root-cause prompts (select all that apply)","HelpText":"Use these prompts to guide a short investigation—you can select multiple.","Required":false,"Options":[{"Value":"equipment","Label":"Equipment / tooling"},{"Value":"procedure","Label":"Procedure / missing standard work"},{"Value":"training","Label":"Training / skill"},{"Value":"human_error","Label":"Human error / attention"},{"Value":"materials","Label":"Material / parts"},{"Value":"environment","Label":"Environment / housekeeping"},{"Value":"supervision","Label":"Scheduling / supervision"},{"Value":"design","Label":"Product / process design"},{"Value":"other","Label":"Other"}]},{"Key":"short_corrective_actions","FieldType":"textarea","Label":"Short corrective actions (what we will do next)","HelpText":"List quick fixes to remove the immediate hazard. Keep it short and assign an owner below.","Required":true},{"Key":"preventive_actions","FieldType":"textarea","Label":"Short preventive actions (to stop recurrence)","HelpText":"Ideas for preventing the root cause from repeating—process changes, training, guards, SOP updates.","Required":false},{"Key":"immediate_owner","FieldType":"text","Label":"Immediate owner (who will act)","HelpText":"Name or role responsible for the short corrective action.","Required":true},{"Key":"follow_up_due","FieldType":"text","Label":"Follow‑up due date","HelpText":"Enter a target date for verification (e.g., 2026-09-20).","Required":false},{"Key":"verification_done","FieldType":"yesno","Label":"Has the corrective action been verified?","HelpText":"To be completed after follow-up verification.","Required":false},{"Key":"communication_plan","FieldType":"textarea","Label":"Communication plan","HelpText":"How will this be shared (shift huddle, bulletin, toolbox talk)? Who needs to know?","Required":false},{"Key":"shareable_learning_summary","FieldType":"textarea","Label":"Quick learning summary for huddle (1–2 sentences)","HelpText":"A short, shareable message you can read at the next safety huddle. E.g., 'Stopped machine after guard was missing; temporary fix installed; SOP updated and operator retrained.'","Required":true},{"Key":"permission_to_share","FieldType":"radio","Label":"Permission to share learning summary across site?","HelpText":"This helps safety decide distribution scope.","Required":true,"Options":[{"Value":"yes","Label":"Yes — share freely"},{"Value":"limited","Label":"Share only with my team/shift"},{"Value":"no","Label":"Do not share outside consults"}]},{"Key":"non_punitive_acknowledgement","FieldType":"yesno","Label":"Non‑punitive acknowledgement","HelpText":"Check yes to acknowledge you understand this report is intended for learning and improvement, not punishment.","Required":true},{"Key":"additional_notes","FieldType":"textarea","Label":"Additional notes or actions needed","HelpText":"Any other observations, suspects, or items to inspect.","Required":false}],"AllowAnonymous":true}