# Form - Near-Miss and Good-Catch Report > Fire Service Safety Management System, version 0.3.3 (2026-10-25). The Human Factor. Document FSSMS-FRM-49. > > Canonical: https://thehumanfactor.ca/library/fire-service-safety/form-near-miss-and-good-catch-report > > Licence: CC BY-NC-SA 4.0 with the Adopting Agency Grant (https://creativecommons.org/licenses/by-nc-sa/4.0/) > > General information only, not legal, medical or other professional advice. Verify every requirement against the current official text of the law, standards and manufacturer instructions that apply to you. Obtain your own legal review and consult your joint health and safety committee before adopting anything. You adopt, adapt, implement and rely on this material entirely at your own risk and on your own responsibility. Full terms: Terms of Use, thehumanfactor.ca. ## Purpose and use The 60-second report. It lives on a QR code on every apparatus and station wall, as a paper copy in every apparatus, and as the script the on-duty district chief uses when a member phones one in. Anyone may report anything that nearly caused harm, or that was caught before it did. Reports may be anonymous. The health and safety officer acknowledges every report within five working days and tells the reporter what happened within 30 days ([Incident Investigation and Learning Program](https://thehumanfactor.ca/library/fire-service-safety/incident-investigation-and-learning-program) element 5.1). The form is deliberately short. Research with volunteer brigades found that people report when it is simple and when they know what happens as a result [(NZFS, 2016b)](https://thehumanfactor.ca/library/fire-service-safety/form-near-miss-and-good-catch-report#ref-nzfs-2016b). The design answers the accreditation criterion that near-miss reporting be used to teach and share lessons [(CPSE, 2019, criterion 11A.6)](https://thehumanfactor.ca/library/fire-service-safety/form-near-miss-and-good-catch-report#ref-cpse-2019). ## The form > **This report is for learning.** What you write here will not be used for discipline or performance management and will not go in anyone’s personnel file. You do not have to give your name. If you do, it is only so we can tell you what happened. ([Policy - Incident, Injury, Exposure and Near-Miss Reporting and Investigation](https://thehumanfactor.ca/library/fire-service-safety/policy-incident-injury-exposure-and-near-miss-reporting-and-investigation) section 8) | \# | Question | Answer | |:---|:---|:---| | 1 | **What happened?** (plain words; a sentence or two is enough) | | | 2 | **Where and when?** (station, address or location; date; about what time; what kind of call or task) | | | 3 | **What could have happened?** (what was the worst it might have been) | | | 4 | **What stopped it, or what would have?** (what the crew did, what equipment helped, or what was missing) | | | 5 | **What do you think would prevent it next time?** | | | 6 | **How can we reach you if you want to hear back?** (optional: name, station, phone or email) | | Type of report (tick one): ☐ Near miss ☐ Good catch ☐ Something that went well and should be studied ☐ Not sure, you decide **Thank you. You just made the next call safer.** ## Office use (completed by the health and safety officer) | Field | Entry | |:---|:---| | Report reference | | | Date and time received; route (QR, paper, phone, oral to officer) | | | Acknowledged to reporter (date; or “anonymous”) | | | Triage date and tier set ([Form - Event Triage Record](https://thehumanfactor.ca/library/fire-service-safety/form-event-triage-record)) | | | Related program and station | | | Register item(s) opened | | | Feedback to reporter (date; summary) | | | Included in quarterly near-miss digest (yes / no; issue) | | | De-identified on (12 months after receipt) | | ## Fields | Field | Type | Required | Who completes | |:---|:---|:---|:---| | What happened | Free text | Yes | Reporter | | Where and when | Free text (location; date; approximate time; call or task type) | Yes | Reporter | | What could have happened | Free text | Yes | Reporter | | What stopped it, or would have | Free text | Yes | Reporter | | What would prevent it next time | Free text | No | Reporter | | Contact for feedback | Free text; optional | No | Reporter | | Type of report | Single choice: near miss; good catch; went well; not sure | No | Reporter | | Report reference | System-generated identifier | Yes | Records system or HSO | | Date and time received; route | Date-time; single choice | Yes | HSO | | Acknowledged to reporter | Date; or “anonymous” | Yes | HSO | | Triage date and tier | Date; single choice: Tier 1, 2, 3; clear Tier 1 (daily log) | Yes | HSO from the Triage Group | | Related program and station | Lookup | Yes | HSO | | Register items opened | Reference list | No | HSO | | Feedback to reporter | Date; free text | Yes where contact given | HSO | | Quarterly digest | Yes/no; issue number | No | HSO | | De-identified on | Date | Yes | Records system | ## Phone script (for the on-duty district chief) “Thanks for calling this in. I am going to write it down as you say it; it is for learning and will not be used against anyone. What happened? Where and when? What could it have been? What stopped it? What do you think would prevent it? Do you want to hear back, and if so how do I reach you? Thank you. The HSO will acknowledge this within five days.” ## Records Kept in {{Records system}} per [05 Document Control and Records](https://thehumanfactor.ca/library/fire-service-safety/document-control-and-records). De-identified 12 months after receipt; the de-identified record is kept for the department’s near-miss database and for external sharing with the fire chief’s approval. > **Note: Customize** > > Add the department’s QR code and phone number to the printed form. Decide whether the “went well” option is shown on the public form or only on the officer’s version. Translate into French where the department works in both languages. ## References Center for Public Safety Excellence \[CPSE\]. (2019). *Fire and emergency service self-assessment manual* (10th ed.). Commission on Fire Accreditation International. New Zealand Fire Service \[NZFS\]. (2016b). *Report 158: Improving the safety culture and practices of rural fire personnel in relation to near-miss reporting* (prepared by Heathrose Research). Hosted by Fire and Emergency New Zealand.