Near-Miss Report & Learning Form

{ "Title": "Near-Miss Report", "IntroductionHtml": "

Use this brief, non-punitive form to capture near misses quickly so your team can learn and prevent future incidents. Be factual and objective. Fill fields you can and submit—someone will follow up if needed.

", "SubmitLabel": "Submit Near-Miss", "SuccessMessage": "Thank you. Your report has been recorded for review and follow-up. If immediate danger exists, follow your emergency procedures before using this form.", "DataType": "NearMissReport", "SchemaVersion": "1.0", "Fields": [ { "Key": "reporter_name", "FieldType": "text", "Label": "Your name (optional)", "HelpText": "Enter your name if you want a follow-up. Leaving blank keeps the report anonymous.", "Required": false }, { "Key": "reporter_role", "FieldType": "text", "Label": "Your role / job title (optional)", "Required": false }, { "Key": "date_time", "FieldType": "text", "Label": "Date and time of near miss", "HelpText": "Use YYYY-MM-DD HH:MM if possible.", "Required": true }, { "Key": "location", "FieldType": "text", "Label": "Location (area, line, machine)", "HelpText": "Be specific so the team can find the place quickly.", "Required": true }, { "Key": "description", "FieldType": "textarea", "Label": "What happened? (objective description)", "HelpText": "Describe the sequence of events briefly and objectively. Avoid assigning blame—focus on facts.", "Required": true }, { "Key": "people_involved", "FieldType": "textarea", "Label": "People involved or affected (roles, not names required)", "HelpText": "E.g., operator, maintenance tech, QA inspector. Note any injuries if present.", "Required": false }, { "Key": "immediate_containment", "FieldType": "textarea", "Label": "Immediate actions taken to contain or stop the hazard", "HelpText": "What was done right away to prevent harm or damage? (e.g., stopped machine, isolated area)", "Required": true }, { "Key": "injury_occurred", "FieldType": "yesno", "Label": "Was anyone injured?", "HelpText": "If yes, follow your reporting and medical procedures in addition to completing this form.", "Required": true }, { "Key": "severity", "FieldType": "scale", "Label": "Severity if event had not been contained", "HelpText": "Estimate potential impact on people, equipment, product, or service (1 = very low, 5 = very high).", "Required": true, "Min": 1, "Max": 5 }, { "Key": "root_cause_prompts", "FieldType": "checkbox", "Label": "Possible contributing factors (check all that apply)", "HelpText": "Use these prompts to help thinking. Choose any that seem relevant.", "Options": [ { "Value": "equipment", "Label": "Equipment / tooling" }, { "Value": "procedure", "Label": "Procedure or work instruction" }, { "Value": "materials", "Label": "Materials / parts" }, { "Value": "environment", "Label": "Work environment (lighting, housekeeping, layout)" }, { "Value": "training", "Label": "Training or competency" }, { "Value": "human_factors", "Label": "Human factors (fatigue, distraction)" }, { "Value": "supervision", "Label": "Supervision / staffing" }, { "Value": "other", "Label": "Other (explain below)" } ], "Required": false }, { "Key": "other_contributing", "FieldType": "textarea", "Label": "If you selected Other or want to explain contributing factors, say more here", "Required": false }, { "Key": "learning_summary", "FieldType": "textarea", "Label": "What did we learn?", "HelpText": "Summarize the key insight the team should remember.", "Required": true }, { "Key": "low_effort_prevention", "FieldType": "textarea", "Label": "List low-effort prevention steps (what can be done quickly)", "HelpText": "Practical, low-cost steps that reduce recurrence—include small changes, communication, barriers, signage, or quick fixes.", "Required": true }, { "Key": "prevention_owner", "FieldType": "text", "Label": "Who is assigned to implement the prevention steps? (name or role)", "HelpText": "Assign an owner responsible for follow-up.", "Required": true }, { "Key": "follow_up_required", "FieldType": "yesno", "Label": "Is follow-up or a deeper investigation required?", "Required": true }, { "Key": "follow_up_due", "FieldType": "text", "Label": "Follow-up due date (optional)", "HelpText": "Use YYYY-MM-DD if possible.", "Required": false }, { "Key": "additional_notes", "FieldType": "textarea", "Label": "Additional notes or context", "Required": false }, { "Key": "consent_share", "FieldType": "yesno", "Label": "I agree this report may be shared (anonymized as needed) for team learning", "Required": true } ] }