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STFPD1 Near Miss Report
This form is intended to bring to light near miss incidents that occur within St. Tammany Fire District #1. The Data on this form is forwarded anonymously to the Safety Committee as well as the Training Staff. The purpose of this form is not to blame or cause disciplinary action toward anyone involved, but rather develop training or control measures in an effort to minimize unnecessary risks to our members.
Please describe the incident as completely as possible while keeping names of those involved confidential. So we can all return home.
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Where did incident occur ?
Station
Responding to a Call
Returning From Call
Emergency Scene
Non - Emergency Driving
Office / Clerical / Admin Area
Other:
Clear selection
Brief History of the Incident ( No Names Please )
Be as specific as possible but maintain anonymity
Your answer
Describe Incident
Your answer
How many hours into the shift did the incident occur?
If you worked a double shift, count hours from beginning of first shift.
Your answer
Time of the Incident
Your answer
Lighting Conditions / Weather
Inside - Good lighting
Inside - Poor lighting
Outside - Bright Daylight
Outside - Overcast
Outside - Rain
Outside - Dark
Outside - Foggy
Other:
Clear selection
What do you believe caused this incident?
Your answer
What would you do to prevent this incident from happening in the future?
Your answer
If you wish to be contacted in reference to this report, fill in your name, phone number, and email below.
Your answer
Comments
List any suggestions to improve this program
Your answer
Item Number
Enter Item Number associated with this event below (Optional)
Your answer
GO TO BOTTOM OF THIS PAGE AND SUBMIT
Do not answer the questions below, these are for Safety Division and Safety Committee use.
Date Reviewed by Safety Division
MM
/
DD
/
YYYY
Comment and Findings
Your answer
Action Taken
Your answer
Satus
Closed
Referred to Safety Committee
Other:
Clear selection
Status Date
MM
/
DD
/
YYYY
Safety Committee Review Date
MM
/
DD
/
YYYY
Safety Committee Discussion
Your answer
Safety Committee Findings
Your answer
Actions Taken
Your answer
Date Actions Completed
MM
/
DD
/
YYYY
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This form was created inside of St. Tammany Parish Fire Training.
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