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

Date / Time

* 2. Visibility at time of event?

* 3. What agency did this occur at?

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

* 5. What was your participation in the event?

* 6. Near miss event type (choose two)

* 7. Near miss event occurred:

* 8. Contributing factors (select up to 5)

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

* 10. Describe what occurred

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

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

* 13. License level

* 14. EMS Experience at time of event

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

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

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

* 18. Type of agency

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

* 20. Shift structure of provider organization

T