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

Date / Time

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* 2. Visibility at time of event?

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* 3. What agency did this occur at?

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

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* 5. What was your participation in the event?

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* 6. Near miss event type (choose two)

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* 7. Near miss event occurred:

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* 8. Contributing factors (select up to 5)

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

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* 10. Describe what occurred

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

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

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* 13. License level

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* 14. EMS Experience at time of event

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

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

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

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* 18. Type of agency

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

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* 20. Shift structure of provider organization

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