What was the date  and time of the incident?

Question Title

* 1. What was the date  and time of the incident?

Date / Time
Visibility at time of event?

Question Title

* 2. Visibility at time of event?

What agency did this occur at?

Question Title

* 3. What agency did this occur at?

Type of service area where near miss occurred?

Question Title

* 4. Type of service area where near miss occurred?

What was your participation in the event?

Question Title

* 5. What was your participation in the event?

Near miss event type (choose two)

Question Title

* 6. Near miss event type (choose two)

Near miss event occurred:

Question Title

* 7. Near miss event occurred:

Contributing factors (select up to 5)

Question Title

* 8. Contributing factors (select up to 5)

What prevented injury, illness, or damage in this event?

Question Title

* 9. What prevented injury, illness, or damage in this event?

Describe what occurred

Question Title

* 10. Describe what occurred

Lessons learned (What are your suggestions to prevent a similar event? Think back to contributing factors)

Question Title

* 11. Lessons learned (What are your suggestions to prevent a similar event? Think back to contributing factors)

What system changes could be made to reduce the chance of this event re-occurring?

Question Title

* 12. What system changes could be made to reduce the chance of this event re-occurring?

License level

Question Title

* 13. License level

EMS Experience at time of event

Question Title

* 14. EMS Experience at time of event

Time off of provider involved before beginning of the shift in which the near miss occurred

Question Title

* 15. Time off of provider involved before beginning of the shift in which the near miss occurred

How many hours was the provider into the shift on which the near miss occurred

Question Title

* 16. How many hours was the provider into the shift on which the near miss occurred

Did the event occur immediately following other employment or additional shifts?

Question Title

* 17. Did the event occur immediately following other employment or additional shifts?

Type of agency

Question Title

* 18. Type of agency

Average number of EMS responses by provider involved in near miss

Question Title

* 19. Average number of EMS responses by provider involved in near miss

Shift structure of provider organization

Question Title

* 20. Shift structure of provider organization

T